Sometimes I forget how long the debate over abdominal hollowing (drawing in) vs. bracing has been going on. We’re close to 20 years on this topic. A year and half ago I started writing a clinical commentary on a herniated lumbar disc rehabilitation protocol which included addressing this very topic. A recent resurgence in interest regarding core stability (I guess it never really goes away) made me want to pull an excerpt from the article before it is published. I believe there is a time and a place for abdominal hollowing and abdominal bracing, but there is also a time for neither. The “neither part” has further been bolstered by my experience with Gary Gray’s Applied Functional Science (See Learning about Movement – Part 1). Here is the excerpt:

“Selective recruitment of the TA and multifidi utilizing “abdominal hollowing” or “drawing in” has been described in the literature and is widely practiced. (88,90) In contrast, the simple “abdominal bracing” exercise is another common exercise which not only emphasizes TA and multifidi recruitment, but has demonstrated recruitment of other musculature of the abdominal wall including the internal and external obliques.(89,91) Hodges et al.(85) have demonstrated, using an in vivo porcine model, some increased intervertebral stiffness utilizing TA activation by replicating “hollowing”, more recently, authors have demonstrated that this increased stiffness from “hollowing” is significantly less than during “abdominal bracing” due to decreased activation of the remainder of the abdominal wall musculature. (91,92) When sudden posterior trunk perturbations are introduced, abdominal bracing yielded significantly greater cocontraction of the trunk musculature, increased trunk stability, and better resistance to lumbar displacement than abdominal hollowing.(93) It also appears that the greater the conscious effort utilized to activate the muscular wall, the greater the decrease in spinal stability.(94) Abdominal hollowing has been shown to cause sufficient inhibition of the erector spinae and other musculature to decrease anterior pelvic during hip extension.(95) Inhibition of the erector spinae may have specific therapeutic and treatment benefits in addressing potential muscular imbalances, however they are valuable contributors to stable functional movement, which may result in decreased pelvic control if inhibited.

Although cocontraction of the TA and multifidi has been perceived as vital for muscular stabilization of the lumbar spine, their attempted selective activation may decrease anteroposterior trunk stability,(91-94) theoretically placing rotational trunk stability at risk through decreased activation of the external obliques in comparison to abdominal bracing.(89,91) Despite this, utilizing “hollowing activity” in the early in treatment phases of treatment can provide some symptom relief, kinesthetic awareness, motor control education, and provide some early activation of the TA and multifidi during the acute phase. However, once an individual progresses to postures that involve weight bearing, utilization of bracing may be better to enhance multiplanar stability.

Ultimately, conscious efforts towards bracing and/or hollowing do not contribute toward functional stability, rather, focus should be redirected towards addressing specific motor patterns utilizing multiple muscles in order to develop comprehensive spinal stability.(96) Moreover, from a theoretic functional perspective, consciously constraining movement in any region of the body over an extended period of time may alter the demands placed upon numerous other regions of the body. This may be best illustrated with the influence of external fixation, such as the use of a spinal orthosis for reducing pelvic mobility,(97) single segment spinal fusion influencing segmental motion around it,(98) and the increased risk of degeneration above and below the segment of lumbar fusion.(99) Although these examples entail extreme measures of stabilization beyond the level produced consciously by an individual, it serves as a reminder that a balance between mobility and stability is necessary to enable responses to the dynamic demands during movement of the human body.”

85. Hodges P, Kaigle Holm A, Holm S, et al. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In vivo porcine studies. Spine (Phila Pa 1976). 2003;28(23):2594-2601. doi: 10.1097/01.BRS.0000096676.14323.25.
88. Richardson CA, Jull GA. Muscle control – pain control. what exercises would you prescribe? Manual Therapy. 1995(1):2-10.
89. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine (Phila Pa 1976). 2002;27(4):399-405.
90. Hides J, Wilson S, Stanton W, et al. An MRI investigation into the function of the transversus abdominis muscle during “drawing-in” of the abdominal wall. Spine (Phila Pa 1976). 2006;31(6):E175-8. doi: 10.1097/01.brs.0000202740.86338.df.
91. Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabi. 2007;88:54-62.
92. Stanton T, Kawchuk G. The effect of abdominal stabilization contractions on posteroanterior spinal stiffness. Spine (Phila Pa 1976). 2008;33(6):694-701. doi: 10.1097/BRS.0b013e318166e034.
93. Vera-Garcia FJ, Elvira JL, Brown SH, McGill SM. Effects of abdominal stabilization maneuvers on the control of spine motion and stability against sudden trunk perturbations. J Electromyogr Kinesiol. 2007;17(5):556-567. doi: 10.1016/j.jelekin.2006.07.004.
94. Brown SH, Vera-Garcia FJ, McGill SM. Effects of abdominal muscle coactivation on the externally preloaded trunk: Variations in motor control and its effect on spine stability. Spine (Phila Pa 1976). 2006;31(13):E387-93. doi: 10.1097/01.brs.0000220221.57213.25.
95. Oh JS, Cynn HS, Won JH, Kwon OY, Yi CH. Effects of performing an abdominal drawing-in maneuver during prone hip extension exercises on hip and back extensor muscle activity and amount of anterior pelvic tilt. J Orthop Sports Phys Ther. 2007;37(6):320-324.
96. Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine (Phila Pa 1976). 2004;29(11):1254-1265.
97. Konz R, Fatone S, Gard S. Effect of restricted spinal motion on gait. J Rehabil Res Dev. 2006;43(2):161-170.
98. Schwab JS, DiAngelo DJ, Foley KT. Motion compensation associated with single-level cervical fusion: Where does the lost motion go? Spine. 2006;31(21).
99. Putzier M, Hoff E, Tohtz S, Gross C, Perka C, Strube P. Dynamic stabilization adjacent to single-level fusion: Part II. no clinical benefit for asymptomatic, initially degenerated adjacent segments
after 6 years follow-up. Eur Spine J. 2010;19(12):2181-2189. doi: 10.1007/s00586-010-1517-4.

This is part 1 of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. I hope to be able to do this on an annual basis as a record of self-reflection and hopefully provide some value to others out there on the same journey.

Applied Functional Science / Chain Reaction™ Biomechanics

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I have previously discussed my interest in going more in depth into multiplanar movement with my posts on 3D stretching as well as regional interdependence. I have used the FMS and SFMA off and on for a few years and felt they were both efficient and useful for their respective purposes, and I love that the research community is actively exploring the validity and reliability of these tests. I will still utilize components of these tests from time to time. However, I have personally found I need to change to a more customized approach to evaluation. In the past, I have found that in the middle of testing, I would break out of the protocols established trying to “tease” out something that did not fit cleanly into any of the tests. Part of this is just my nature, I have a difficult time adhering to standardized procedures and the way I do things just kind of evolves and varies depending by how I perceive something is presented to me. As these breakout sessions grew in complexity, I knew that for me personally I needed to explore some other philosophies which probably have figured out things I have yet to even think to ask about. Gary Gray’s Applied Functional Science (AFS) was the first approach that peaked my interest after that point. Gary Gray arguably pioneered much of the functional training movement, with Gray Cook stating publicly he has been strongly influenced by Gary Gray’s thought process. However, getting to the point of wanting pursue learning about the AFS approach has been a 4 year journey. When I first watched videos of Gary demonstrating and discussing his thought process, I completely disregarded it because my bias at the time of what I was seeing was an awful amount of poor quality movement with no regard for what is currently considered stability, in particular with movement of the spine. But over time, I could not deny that this freedom of motion looked more useful than I had first thought. I finally bit my lip and jumped in, eventually realizing I need to at least give it a try. It was probably one of the best decisions I could have made and now has significantly influenced how I view movement and exercise prescription.

I was given the opportunity to be exposed to the AFS approach through a nine week clinical rotation at Shoreline Sport & Spine in Spring Lake, MI. There are currently 6 Fellows of Applied Functional Science™(FAFS) at this location. A FAFS has completed a 40 week fellowship through Gary Gray’s Applied Functional Science (AFS) approach. The clinicians at Shoreline have integrated AFS with a wide variety of manual therapies and other interventions which was a fantastic eclectic experience that allowed me to explore a number of ways to integrate this philosophy.

Before presenting on this topic, I must first acknowledge that these are my personal reflections on the experience, and if they are in error, they should not reflect upon the excellent clinicians at Shoreline Sport & Spine. I am certain more than one FAFS will perceive I might have missed the boat on key points, and to that, I respond that I plan to formally take a Chain Reaction™ course in the future to see what else I might have missed. Furthermore, I am commenting on but a drop in the ocean of what the AFS system entails. The “Functional Nomenclature” alone requires a 44 page manual to address simply the language and fundamental principles. That being said, here are some key things I learned from this experience:

“Drivers facilitate chain reactions throughout the body”

This was the earliest, most applicable, concept I learned from my exposure to the AFS/Chain Reaction model. It may seem like a simple statement but it is incredibly profound when broken down even a small amount. Rather than simply thinking about one joint moving on another and leaving it at that, the Chain Reaction model demands that every joint be examined from a proximal on distal and distal on proximal perspective, what are the joints above and below doing, and what planes of motion (sagital, frontal, transverse) all of the joints are moving in during any musculoskeletal action. Central to this is the concept that during movement, a driver leads the movement and the joints above and below follow that same movement, but at different speeds as they progressively move in the direction dictated by the driver. This delay in speed/timing of a bone following another bone is the Chain Reaction explanation for much of what we understand about arthrokinematics. When bones move on top of each other in multiple planes of motion in the various representations of roll, glide, spin, etc.,  they are doing so according to the congruencies afforded to them to allow them to follow the next bone and joint as led by the driver.

In most of our manual therapy courses, we examine relative motion of one joint on another and addresses joint movement in various planes of motion based on arthrokinematics. Traditionally, looking at joints this way was left to the manual therapy realm and not the exercise prescription realm. Oddvar Holten likely made the earliest attempt to merge the manual therapy perspective with exercise prescription with his Medical Exercise Therapy (MET – Not to be confused with muscle energy technique) which focused on utilizing various apparatuses to isolate spinal segmental levels and extremities and then focusing on patient induced movement into one or more planes of motion specific to the desired outcome determined in the manual therapy diagnosis. The Chain Reaction approach more broadly addresses this by including concepts more similar to regional interdependence and primarily using the patient’s own body and extremities to control the levels of segmental or joint emphasis through prepositioning such as: Holding on to a stable or unstable support, modifying the weight bearing surface (wedges, angles, instability), conscious prepositioning, etc. It then utilizes another joint or point of the body above or below (could be FAR above or below) to facilitate movement at the joint in the plane, or planes, desired. This approach is both a diagnosis and a treatment, which is the focus of the AFS approach. It integrates extremely well with existing manual therapy interventions, or in Gary’s opinion, independent of traditional manual therapy models, resulting in him developing his own manual therapy system specific to the AFS called Functional Soft Tissue.

Getting back to the idea of a “driver”. A driver is anything which “drives” motor behavior. This could be any part of the upper extremity, lower extremity, trunk, neck, head, eyes, sense organs, and/or even fears and beliefs. The driver itself has numerous variables which can be applied to it: Is it open or closed chain based? What action is performed? What is the direction of movement? What is the speed? What are the force demands? Etc. etc.. This is just a small list amongst many other variables, not even addressing fears and beliefs.  The entire process can get very complex, very quickly, when broken down in the nomenclature which requires looking at every movement from the perspective of:

  • What environment is it occurring in (given available, or specified with certain controls on stability)?
  • What is the beginning position (upright, seated, kneeling, prone, supine, sidelying)?
  • What exactly is the driver (hand, knee, foot, pelvis, trunk, shoulder, etc)?
  • What is the triangulation (direction/target)?
  • What is the action (squat, lunge, reach, pull, etc)?
  • What is the ending position?

I am not qualified to go into that sort of detail, so instead I will provide a broad overview with a contemporary example. Many of us are already applying general versions of this thought process, but do not realize how far we can take it. I will use the example of a kettlebell swing.

 Kettlebell Swing

If you give a new client a kettlebell and only cue them to swing the kettlebell, they will instinctively “drive” the motion using the arms and shoulders, not their hips as you may have originally intended. They do this because you just gave them a cue which facilitates a motor pattern to accomplish the goal in the simplest way the brain understands, which is to swing their arms to swing the kettlebell, rather than to accomplish the exercise prescription goal you had intended, which was likely hip extension. If you change the cue to “Drive the hips forward”, you changed the driver of the motion to the hips, rather than the arms. Now in order to produce the force to swing the kettlebell, the individual will use a hip extension strategy. You just changed the entirety of the neuromuscular patterns utilized, even though you had the exact same exercise setup. Change the driver and the motor behavior changes.  Now, if you expand this to joint by joint, things get really interesting.

Take for example working mobility and stability of hip internal rotation. There are a handful of non-weight bearing activities which involve the femur actively or passively internally rotating on the pelvis.

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We may begin with a manual therapy intervention to address mobility, then provide a mobility exercise, then a stretch, then we prescribe an exercise for stability, then we address another joint which may be associated, and we give it a mobility exercise, and a stretch, and a stabilization exercise, on and on we go. We may end up providing a large amount of exercises, all of which take time, with very specific cues and details to remember. Now with AFS, if we apply the concept of a driver along with any number of subtle changes, or “tweaks” as Gary likes to call them (the process is called “tweakology”), we can tailor a custom exercise specific to our patient needs across multiple joints with reduced need for extensive cuing and details. This can be done with fewer exercises overall because we can integrate mobility, stability, and movement across multiple joints, in multiple planes of motion, into simple exercises which require less time for the patient perform. Progression and regression are simple to teach because you are using movement patterns the client/patient already knows, you simply tweak one or two components to make changes towards the movement you want to improve.

As I am already far over my target word count for this post, I will finish with a video in which I discuss some basic strategies to emphasize hip internal rotation in weight bearing and function:

Movement “flows” are a popular trend in the personal/fitness/strength and conditioning realm these days. “Flows” are a sequence of movements or exercises put end to end and performed in a continuous fashion.  These movements are performed continuously for the desired amount of time or repetitions.  To some extent, they have existed for 1,000 of years in martial arts in patterns of movements called “forms” which paired together martial arts techniques in both short and extremely long sequences (I have learned forms over 10 minutes in length in various styles over the years, and some forms of Tai Chi can be even longer). These grew and evolved to include many acrobatic techniques as well. The value of any these forms are debatable, but for those who enjoy them, they are worthwhile. Similarly, for those who are looking for something different, the current trend of movement flows are worthwhile. After all, movement in life is varied and diverse, not confined to singular patterns. Not to mention that flows can be quickly fatiguing through a variety of changing movements rather than the need to do a high volume of the same exercise.

Over the last few months, I have been toying with the idea of incorporating movement patterns and exercises that I think are generally beneficial to overall movement into standardized flow. As it stands, I have developed two sequences which I have been putting through trials with a variety of victims (read: clients and friends) with positive response. Therefore, I have decided to throw these out to the public for others to try. These flows are great for a warm-up or a stand alone exercise and can be blended together for a physically, and sometimes cognitively, challenging exercise.

Dynamic Principles Basic Flow #1 emphasizes mobility and stability for the hips and shoulders, trunk control, and multiplanar movement driven by both the upper and lower extremities.

Dynamic Principles Basic Flow #2 emphasizes dynamically lengthening the frontal and lateral anatomy lines, multiplanar spinal mobility, and multi-angle hip extension

As always, thoughts and opinions are welcome!

Back in August, a group of authors, van den Bekerom, et al. published an article in the Journal of Athletic Training which reviewed the evidence for the use of RICE in acute ankle sprains1. The authors concluded that, other than some extremely limited and low quality evidence for ice, there is very little evidence for rest, compression and elevation. The most interesting to me, and purpose of this post, was the discussion of rest, which I felt the was best summarized from the article itself: “All included studies had a similar conclusion: some type of immediate posttraumatic mobilization is beneficial in the treatment of acute ankles sprains“. And curiously, although this was a team of medical doctors writing this article, it appeared that form of mobilization was preferentially (not directly stated) manual therapy.

Although I have not had a chance to do a thorough follow-up lit review myself (always a good practice in reviewing systematic reviews), based on references selected by these authors, it appears there is more published evidence (regardless of quality) towards the use of manual mobilization/manipulation2-6 than activity/exercise7-9. Of particular interest was an examination by Eisenhart, Gaeta, and Yens6, which  examined the use of manipulation (fibula, talocrural, cuboid, and anything else clinically determined), soft tissue techniques (fibularis/peroneals, etc.), and lymphatic techniques combined with RICE (with or without pain meds) in comparison to RICE alone (with or without pain meds) in an emergency department. The group which received manual therapy demonstrated decreased pain, decreased edema, and improved dorsiflexion/plantar ROM (ROM was not statistically significant though) compared to group that received RICE alone. Since it typically does not get more acute than patients showing up at the emergency department, I felt this was a great study to demonstrate the value of manual therapy for acute ankle sprains. Combined with evidence that long term restrictions in posterior talar glide post ankle sprains4, there is clearly evidence for some form of early manual therapy in most inversion ankle sprains.

Despite recognizing the increased risk of compensation injury and general increased risk of injury from deconditioning, RICE, in particular rest and relative immobilization, remains the mainstay for the acute inversion ankle sprain. It is my belief (and I am sure many others) that this treatment philosophy needs to change at every level of patient care, and I believe athletic trainers and physical therapists need to lead the way. Although consideration for the individual patient should be made, as a general guideline, if we are presented with a patient with an acute inversion ankle sprain, our thought process needs to move away from the “rest/immobilization” component unless there is a clear need. Obviously “RELATIVE REST”, ie: not return to full sport participation may be a short term need, but full immobilization and crutches for the purpose of non-weight-bearing is likely unnecessary and potentially harmful. Instead, once a fracture or significant traumatic instability is ruled out, make the foot and ankle move, both actively and passively, and ideally with full weight bearing. Clearly if an excessively antalgic gait is present and cannot be resolved with manual therapy, tape, or other modalities, an assistive device may be necessary to improve the quality of gait, but ambulation with gait training to avoid compensation should occur early.

For those who prefer guidelines towards directing treatment, Whitman, et al. 10 developed a CPR for predicting whether thrust, non-thrust manipulation, and exercise in acute inversion ankle sprains could improve outcomes. They were able to determine that the presence of 3 out of 4 variables: Symptoms worse when standing, symptoms worse in the evening, navicular drop greater than or equal to 5.0 mm, and distal tibiofibular joint hypomobility were present; are predictive of dramatic improvements with a 95% success rate in treatment outcomes if manual therapy and exercise interventions are utilized.

To drive home these points I have 2 recent cases I want to share to demonstrate the clinical value of manual therapy in the management of an ankle sprain. Case 1 involves a 55 year old female who recently experienced an acute ankle sprain after waking up in a recliner and getting up rapidly, not realizing her left lower extremity had “fallen asleep”, resulting in a significant inversion of the left ankle and a “not so graceful” landing onto the floor. Initial evaluation revealed she was positive for 3 of 3 of the Ottawa ankle rules, so she was referred for X-ray. X-ray was cleared, she was provided crutches, and she presented to me 16 hours post injury with significant swelling and difficulty weight bearing. I performed distal fibular head mobilizations and talocrural mobilizations which result in immediate visible decreases with swelling without the involvement of any lymphatic techniques. Furthermore, it allowed the patient to weight bearing with 80% decrease discomfort. Additional soft tissue treatments of the peroneals and lateral aspect of her gastroc allowed her to ambulate without an antalgic gait, and without the crutches she arrived with. Although she still reported some mild discomfort, she was able to be off her crutches from that point on. I was able to see her for 2 sessions before she was sent on her own with 90% improvement within a week after her initial sprain. I would have liked to continue to work on the foot ankle, but she was private pay and she was satisfied with the improvements she already had, I discharged her to HEP with self mobs and progressive strengthening and instructions to keep moving. Clearly I can’t say if these outcomes would have been any different had she been partial-weight bearing for a week or more, but I can say that I was able to produce immediate functional improvements which improved the quality of her life sooner rather than later.

Case 2 is a story of me, jumping for a Chinese flying lantern stuck in a tree, not realizing on return to the earth my ankles would need to accommodate to a muddy ditch with a 75 degree decline in a very short amount of time. Unfortunately, they did not accomplish this goal and I crumpled like a sack of potatoes with the right ankle significantly inverted under my collapsing body. Of course I had just read this article from van den Bekerom, so I got right up and tried to avoid limping for the rest of the evening. Keep moving and it will just resolve itself right? Well nearly 2 months later of working through it, doing occasional self mobs or having someone do a talocrural manips, I still had episodes after training or moving where there were a few minutes that I could not weight bear pain free without significant pain on the lateral plantar surface and partially through the mid-foot  In the back of my mind I kind of thought this may be something cuboid related because this was a typical presentation for it, and I somewhat proved it to myself that I got the most relief when I attempted a self mobs of the cuboid using a small kobble tool, but it never lasted. It was not until I had learned that one of my fellow PT students, Nan Hannum had recently been trained in the Dr. Allyn Peelen (a local podiatrist) method of cuboid mobilization that I finally had it formally treated. Although I always have a hard time believing in a “systematic” or sequential approach to mobilization, I have seen and experienced great results with Dr. Peelen’s method of treating cuboid and all sorts of vague ankle/foot  issues that did not resolve with other manual interventions. So I thought, why not have her try it on me, especially  since it had been consistently problematic and interfering with my activity levels. With one treatment, followed by a foam bolster taped under the cuboid to “hold the treatment”, I was 80% percent improved. We repeated that treatment 2 days later, second bout of tape, this time 90% improvement. I took the tape off 3 days later, and was able to run 2 days later for the first time in 2 months (Thanks Nan!). Furthermore, that specific pain has not been back since (although I did tweak my talocrural recently of course). Needless to say, the purpose of this case study was  that I personally believe that if I had the talocrural and the cuboid (along with anything else clinically relevant) mobilization the first week, I would probably never have to wait 2 months to get full relief and I probably would not have developed subtle hip pain secondary the subtle antalgic gait. Yes, from an evidence based perspective that is a stretch, but when you see the acute benefits (regardless of the mechanism) of manual therapy with numerous patients, it is hard not to make the judgment that earlier treatment may have prevent later complication.

So with my rambling out of the way. I leave you with a slew of videos of my favorite ankle mobs. First off, you can’t go wrong with Dr. E’s collection of eclectic strategies to improve ankle mobility:

Second, don’t forget the cuboid whip, personally I have had good experience with this with patients, but as demonstrated with the Peelen cuboid sequence, we probably don’t need to be this aggressive because this can be painful!

Finally, I was able to track down two videos of Dr. Allyn Peel himself both performing and using a plastic model to explain his approach to cuboid/foot ankle mobilization.

Oh, and one last thing, don’t forget about the other 6-8 hours of an acute ankle sprain..

References

1.) van den Bekerom, Michel PJ, et al. What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?. J Athl Train 2012;47(4):435-443.

(2.) Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):7-20.

(3.) Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81(4):984-994.

(4.) Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002;32(4):166-173.

(5.) van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52(1):27-37.

(6.) Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103(9):417-421.

(7.) Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute ligament injuries of the ankle joint. Scand J Med Sci Sports. 1996;6(6):341-345.

(8.) Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J (Clin Res Ed). 1981;21;282(6264):606-607.

(9.) Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964. doi: 10.1136/bmj.cl964.

10.)Whitman, Julie M., et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther 2009,39(3): 188-200.

Most of the time when we deal with an acute inversion ankle sprain, we look at how to manage it for 16-18 hours out of the day and maybe add in some elevation at night if there is significant swelling. But could we do a little more to speed the recovery time or at least decrease the discomfort during the night? If the individual with an ankle sprain sleeps on their back or on their side (if they lay on their stomach, this solution will not work), here is something to try to help mediate some of the acute pain with laying on their back/side with an acute inversion ankle sprain.  This mechanism/solution may seem negligible, but I can assure you that your patient will thank you for at least suggesting this as an option.

Although anatomic variations and pre-existing lack of mobility may prevent this from occurring, but for many, when the leg is rested on a surface, such as in supine with the posterior aspect of the calcaneous in contact with the surface, the effect of gravity naturally places the ankle into a bit of plantarflexion.  With plantarflexion, a concurrent anterior glide of the talus occurs which is slightly accentuated by gravity both on the foot and through the talocalcaneal bridge with the tibula/fibula. This is because the calcaneous acts sort of like a fulcrum in which the talus has a relative anterior glide due to the effect of gravity driving the tibia and fibula gently posteriorly  on the talus towards the resting surface due to size and weight differences. As a result, additional stretching/irritation of the anterior talofibular (ATF) ligament may occur. If the patient rolled on the side which places the injured ankle’s lateral aspect to be faced towards gravity, gravity would then contribute to the foot/ankle invert/adducting and minor stretching/irritation of the calcaneofibular (CF) and ATF ligament. Similarly, having the ankles lateral aspect on the support surface, through bodyweight and lack of conformity of the surface, minor stretching/irritation of the CF/ATF ligament may occur.

One way to counteract this kind of stretching/irritation is with a conforming pillow, which can assist with preventing the amount of plantarflexion in supine, and inversion, in side lying which may occur while laying in bed/couch, etc. But a pillow can be more cumbersome and require a fair amount of adjusting throughout the night to accommodate.  Another way is through a small homemade/athletic training room/clinic made supportive device:

Take a simple piece of foam tubing (IE: pipe insulation tubing or thin floatation device) cut it to a length that can cover the back of the ankle and both malleoli. Thread a piece of string through it to allow it to be fastened around the ankle. Tie the string tight enough to allow it to stay on the ankle above the calcaneous at the talotibiofibular joint, but loose enough to easily remove.

This foam supportive device provides support at the talotibiofibular joint which, in supine, reduces the influence of the posterior glide of the tibia/fibula on the calcaneous (reduced relative anterior glide of talus) and also mildly dorsiflexes the ankle. In side lying, it can be positioned more inferiorly to prevents inversion/adduction with the lateral aspect facing to the sky, and left at the talotibiofibular joint line when the lateral aspect of the ankle is facing the resting surface. Basically, we are trying to prevent additional stretching of the soft tissues associated with anterior glide of talus.

In theory, this may secondarily assist with healing, as it helps keep the ATF,CTF, the capsule, and other tissues in an approximated position. This may be beneficial after aggressive posterior talus mobilization/manipulation as well.

…Ofcourse, everything I just described above could be complete hocum and simply the additional sensory contact around the ankle could act like a counter-irritant. Regardless, speaking from experience, it just feels better.

The discussion about the value of a dynamic warm-up in movement preparation is fairly focused on dynamic stretching these days. If you need a brief primer on pre-exercise dynamic stretching, please visit this old write-up of mine here. Now debates occasionally arise regarding what the “optimal” dynamic warm-up or movement preparation approach is. Tons of articles, books, and even training programs encompass very specific “functional” activities as a part of the warm-up. While I personally think that some degree of specificity is needed for each individual sport, there may be times we get a little excessive in this vein. A recent article from  Sander et al. sparked my interest on this topic. In their study, they took a group of elite youth soccer players (making some limitation of the practicality to 13-18 years olds), split them into two, one with a very generic warm-up (although they did include various running drills which are functionally specific to sprinting) and a second which did the generic warm-up plus additional “functional exercises”.  They found that for linear sprints and change of direction sprints, no significant difference was noted between the two groups. In other words, besides just “getting warmed up”, some of the classic “functional dynamic warm-ups” did not add any additional benefit to the performance of a sprint task. This leaves a great deal of room for argument regarding how this would apply to the broad scope of movements of sports beyond sprinting, but it still shows you don’t have to spend 15-20 minutes doing a complex dynamic warm-up to be able to a physically demanding task such as sprinting.

This was interesting to me because I have been playing around with the use of an intervals for movement preparation in recent months as method of making shorter warm-ups, and the feedback I have received so far has been positive.  Intervals have been extremely popular in recent years for “metabolic training” and fat loss programs based on various interpretations (some grossly inaccurate) of the original Tabata protocol and other historical interval/circuit training research. However, another possible use for intervals are as a generic/semi-specific warm-up.

When performing an interval for a warm-up, the intensity is perceived as high, but the rest intervals, exercise selection, and exercise order prevents early overwork and burn out. Time is saved from the exclusion of a general warm-up, and the movement specific components can be incorporate as a part of the interval model (although more will be necessary if full sport participation is planned).

Currently, I use 30 seconds on, 10 seconds off, for 10-20 rounds  (5-10 mins of actual work) depending on the demands for the session. In these 10-20 rounds I select a matching number of alternating light, moderate, and higher intensity full body exercises which generally involve the primary movers and stabilizers for most sports. Typically, I use a number general low risk contemporary exercises which can be easily graded for intensity, such as heavy ropes, kettlebell deadlifts, hand walk ups on unstable surfaces, farmers walks, etc. If limited equipment is available (on field, etc.) most of the intervals are body weight.

Although I can’t state there are unique physiological benefits from an interval model, theoretically it shares the same benefits of increasing heart rate, blood flow, increased neuromuscular recruitment, provide the ROM demands of the activity, and most importantly, being interesting and challenging enough to get the central nervous system fired up and therefore “wake” the athlete up for training. If I’m honest, it’s not really much different than most dynamic warm-ups except earlier increases in intensity and using a timer rather than reps and sets. But that’s what makes it different from a psychological perspective. Just having the warm-up “be different” is valuable to me, because after nearly 10 years of sets and reps of rather low intensity progressive dynamic warm-ups, sometimes you just want something different, and often times, so do your athletes.

Below is a video of a sample interval warm-up for a small group training session. Since the goal of the warm-up was to prepare for some backyard strength training, no sport specific components were a part of the training session. This session was shorter than what I typically use, consisting of 7 rounds for 3 minutes and 30 seconds of actual work. But it was still more than adequate to warm-up everyone to be able to do what they needed to do in the proceeding training session, showing how the interval model can save quite a bit of time in compressed training sessions.

Sample Interval Breakdown

**Note: With groups, it is more difficult to grade intensity of exercises since an individual starts at any station, so every exercise has to be selected as if it can be tolerated as the athlete’s first exercise if they were “cold”.

  • Weighted stair/box stepping – Hip extension patterning, unilateral & quick heart rate elevation
  • Kettlebell deadlift – Hip extension patterning, requires less spine/hip flexion than tradition DL & much lower load, and some core activation.
  • Floor mover reaches – Scapular/RC activation, some core, and mobility.
  • Floor mover mountain climbers – Quick heart rate elevation, and mobility.
  • Heavy rope battling ropes – Heart rate elevation, scapular/RC activation, and some core activation.
  • Sandbag hand walk-ups – Core activation and scapular/RC activation.
  • Isometric grip strength – This was partially a rest station, but was also to prepare for the gripping components of the training session for the day.

P.S. Yes, I love to keep it classy by shooting these videos in my trashed basement gym. The record has been a small group of 10 victims squeezed in here.

A few months ago I talked about the Gluteus Maximus Activation Enigma and the conflicting information obtained on the glute max in the clinic versus what has been demonstrated in literature. It has been difficult for me to address this because I too was guilty of really perpetuating the idea of “gluteal inhibition” and that your “glutes are shut off”, when the evidence for these theories does not exist unless you have a true nerve lesion. It may seem like semantics to the some, but the reality is that our patients and clients take these words very seriously. In fact, I would say a good chunk of them catastrophize the fact that their “glutes aren’t working” and likely worsen the associated symptoms involved in the hip extension dysfunction. I think for athletes in particular to be told that something isn’t working in their body is detrimental to performance for individuals with certain psyches, a point which Vern Gambetta really drives home with his opinion on corrective exercise. At the same time, even if the glutes truly are not “Turned off” or “Firing in the wrong order”, clinically, they are clearly not working very efficiently either, especially if they are significantly asymmetrical. Therefore to find middle ground, I like to look for solutions which help the client/patient remain independent while still participating in their sport even if some form of dysfunction exists by using self evaluation and treatment. I previously mentioned my suspicion that muscle fatigue, rather than muscle inhibition or activation order, may play a part in why our glute emphasized treatments result in reduction of symptoms. A recent article from Hong-You Ge, et al.1 demonstrated that latent trigger points have measurable effects on muscle fatigue made me want to revisit fatigue in the evaluation and treatment of general hip extension dysfunction.  However, I’m going to broaden this idea even further (I’m once again breaking my own rules regarding excessive extrapolation of a research study by doing so) by first looking at addressing the antagonists to hip extension, the hip flexors, prior to attempting to address trigger points/restriction in the gluteals.

I want to preface this write-up to make it clear that I have no evidence for the process that I am about to describe and I am certain there are at least 10 other ways to independently evaluate hip extension. I think both Stuart McGill and Bret Contreras have touched on the use of  different types of bridges in determining hip extension dysfunction in the past, but I couldn’t find the articles offhand, so here is my take on it.

I use a 15-20 rep range of single leg bridges for the patient/client to subjectively identify whether they feel a perceived difference between sides relative to fatigue, ease, and whether it feels disproportionately loaded on the hamstrings, possibly even painful if that is their primary complaint. Then, based on which side is perceived as more challenging, we slightly butcher the classic Janda lower cross syndrome2 and just associate hip flexor involvement with gluteal function rather than look at his original cross of abs to glutes.We’ll generalize it even more and call the hip flexors over active antagonists with possible active or latent trigger points in them decreasing performance of the agonist hip extensors just to integrate the Hong-You Ge et al. 1 discussion a little more.

So for the patient to independently treat this, we start with them attempting to inhibit the hip flexors through a 30 second static stretch for and then retest the bridges. They don’t have to go all the way to 20 reps but they should just be able to go 2-3 more reps more and perceive the exercise as easier. If it does improve, have them do a full minute of static stretching of that hip flexor followed by 3-4 sets of 15-20 reps of single leg bridges to reinforce the more efficient hip extension pattern.  If it doesn’t improve, or they feel only a little better, try a self-TFL release next. Use 1-2 minutes of self release on a tennis ball followed by the same 3-4 sets of single leg bridges discussed earlier.  If they still don’t feel an improvement, go for the glutes directly with a self release. If it works, follow the same pattern of reinforcement from earlier. If there is no change, there is a slim possibility they simply need to train that side more aggressively in hip extension. If this is the case, then we want to have them work on quality reps of single leg bridging on a daily basis for the same pattern of reinforcement as described above. If within one week of working this pattern they still find a single set is fatiguing, the problem does not lie specifically in the hip musculature and it is going to require a bigger picture perspective and likely more involved manual therapy (starting with a pelvic/lumbar eval).

A couple of notes: First off, verify that the fatigue is not just related to the position of their foot and whether they are driving from the heel versus the toes because this can significantly impact loading of the hamstrings between sides.  Second, I recognize not every one of our clients and patients can even do a single leg bridge, let alone 20 of them, but this test and these self-treatment options is not for those individuals anyway. Third, by the 3rd set of bridges, if they’re not used to doing these bridges, they’re going to be fatigued anyway, just do a couple reps for them to subjectively evaluate any chance in the performance of hip extension.

Finally, I admit I am probably still going to use the terms gluteal inhibition from time to time, but I swear I’ll do my best to not give patients or clients the anecdote that their glutes are “shut off” again.

***Update 6/24/12: A great example of when self treatment for hip extension dysfunction fails and more involved manual therapy is needed  from Bill Hartman is found here on his blog.

1. Ge H, Arendt-Nielsen L, Madeleine P. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Medicine. 2012:no-no. doi: 10.1111/j.1526-4637.2012.01416.x.

2. Janda V. Muscle strength in relation to muscle length, pain, and muscle imbalance. International Perspectives in Physical. 1993:83-97.

Ever had an external rib torsion which just would not calm down? I had one of these for about 6 months and a fellow student had theirs for several months as well. Addressing the t-spine and the rib itself both through manual and exercise helped a little, but didn’t seem to resolve it completely. Instead, we were both able to treat it successfully with this amazing tool:

Towel

Yes, a towel. We folded a medium sized towel to approximately 1/2 to a 3/4 inch in thickness. This towel was then placed under the painful rib, and slept on. It was positioned in way that whether you slept on your back or on your side it would maintain a constant level of compression on that rib. At first, the intent was just to reduce discomfort of the rib pain at night, but unintentionally, it became the complete treatment and resolved the issue. It took about 4 nights for me and about 10 days for other student. Problem solved. Easy and safe intervention to use concurrently with manual and therex, or possibly try it by itself?

The Rotator (Demonstrating Internal Rotation)The Rotator (Demonstrating External Rotation)

Chris Melton from Joint Mechanix sent me a free trial of the Rotater back in March. When I first received it, there were a few minutes of blank staring at it trying to figure out which way to hold the Rotater to get it to do what I wanted at the moment. When I finally watched the DVD that was enclosed, I had to smirk when Eric Beard also became confused on which way to hold it in the outtakes. Needless to say, like with anything I review, I took my time to play with it for a while before I make too many comments on it. In addition, because I have a bit of excess ROM in both internal and external rotation, I really did not use the rotator much myself. Instead, I had a few individuals with restrictions try it out and merged their thoughts with what I observed while they were using it. So here is the review:

As is usually the case with anything I touch, I tried to turn the Rotater into something other than it was designed to do. I wanted a lot of stretching and strengthening variations, but that is not the point of the Rotater. The Rotater is what it is. Which is not to say that is bad in any way, it is the best at what it is designed for, which is for self controlled stretching into focused internal and external rotation. This is a good thing, because as has been mentioned before, the greatest part of the Rotater really is the ability of the patient to control the stretch themselves. I have never been a fan of assisted stretching, but IR and ER stretching is difficult to do independently, typically requiring assistance. However, this can be risky, as I have seen partner assisted shoulder stretching sessions resulting in strains and even tears. The Rotater design solves that problem by putting the control back into the hands of the individual themselves, making it great for post-op shoulder surgery, pitchers/throwers, and any individual lacking IR and/or ER. The design also allows IR/ER to be stretched in nearly all ranges of shoulder flexion and abduction which can help with designing functional ROM progressions within post-op restrictions. The Velcro band can also be used as a gentle resistance point for self-administering PNF stretches or even oscillating stretches at the end range if the need arises.

I want to clearly state, that when it comes to addressing limitations of ROM, I still believe the first goal should still be address joint mobility of the effected joint and those around it to see if the ROM limitation clears up without more focused stretching. If it does not, there is still an important place for additional stretching, and in the case of lacking IR/ER in the shoulder, the Rotater really shines in this area!

So what were my concerns and dislikes? At first, I was concerned about the durability of the Rotater, but the reality is it survived a couple of incidences of being stepped on, thrown and dropped, and aggressively being flexed. I thought the amount of flex that occurred with stretching and the strong arm would eventually give and snap it in half, but it has held well and Chris stated the flex was actually there by design for durability. Regardless, they warrant the Rotator all the way around, so if anything were to break they would replace it.

One specific dislike I had was mostly to do with my own personal preferences. I just do not do very much focused IR/ER strengthening with most of the people I work with. So for me I was not entirely sold on the strong arm attachment. It worked as it was intended, but it was time consuming to switch between IR/ER. If an individual needed a very specific range to be worked with tremendous control and only in one direction, it could work well. However, I tend to do more stabilization, eccentric control,  and multi-joint/multi-planar exercises for the shoulder. Although you could use it for controlled stabilization and eccentric control, I prefer getting the entire shoulder involved using another method.

Overall, the beauty of the Rotater is in its simplicity, it does its intended job very well. I commend the team over at Joint Mechanix for putting the Rotator together without an orthopedic rehab background!

The Rotater

The FDA dictates specific uses and indications of a drug based on pharmaceutical trials. These specific uses and indications are “on the label”. Physicians frequently utilize pharmaceuticals “off label” from their branded purpose based on clinical reasoning. This is a legal and widely accepted practice and necessary to treat conditions which at this time may not have the research evidence available to support the practice but has demonstrated good clinical outcomes. The advent of Clinical Prediction Rules (CPR) and subclassifying of conditions towards specific treatment protocols has been growing in the physical therapy realm5,8,12,13. This is particularly true with manual therapy and CPR for joint mobilizations/manipulations for the cervical, thoracic, and lumbar spine. In general, these guidelines tend to be region specific, IE: a lumbar manipulation for a lumbar condition5,8and cervical spine mobilization/manipulation for neck pain12. Although not as well known, predictive factors for the influence of cervicothoracic manipulation on shoulder pain10 and lumbopelvic manipulation in patellofemoral pain syndrome9 have also been proposed. You could say that the advent of CPRs/classifications is the rehabilitation world’s attempt at providing an “on label” guideline for treatment. However, little other attempt has been made to provide subclassifications for conditions and treatments regarding manual therapy interventions on extremity conditions. Clinically, worldwide, many movement professionals treat extremity conditions one to two joints proximally or distally, in particular through addressing mobility at the spine. This practice is based in the idea of regional interdependence, or “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.”18 In an essence, this practice is “off label”, but unlike the pharmaceutical practice, it is not widely accepted and frequently questioned. This is particularly true from a medical billing and, depending on the location, referral/medical prescription level. Even from within our profession itself, it is not terribly uncommon for the concept of regional interdependence to questioned and perceived as a “wild goose chase around the body” 18.  As I have mentioned in previous posts, Thomas Myer’s Anatomy Trains based system KMI, Gray Cook’s SFMA and Gary Gray’s Chain Reaction Biomechanics™/GIFT Fellowship are perhaps the first to develop standardized evaluation and treatment methods of looking at the body globally rather than locally. Although the terminology varies between each, all of these programs have essentially provided a road map towards understanding regional interdependence. I have minimal exposure to all of these programs, so I cannot give justice to any of them trying to give additional details from their models. However, I wanted to share my thoughts on regional interdependence based on the experience I have gained through my mentors, research, and my limited full-time clinical experience thus far.

A JOSPT guest editorial by Wainner, Whitmann, Cleland, and Flynn titled Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come (Freely available directly from JOSPT) written in 2007 probably first popularized the term “Regional Interdependence”, because very little literature prior to this date utilized this term. This editorial presented a great case, both from a clinical and a research perspective, that the practice of examining musculoskeletal conditions beyond the single joint/primarily complaint area is woeful inadequate to address the needs of both common and complicated conditions 18. Research has increasingly been supportive of regional interdependence. Improved pain scores and functional outcomes have been demonstrated painful shoulder conditions as a result of the use of cervicothoracic and rib manipulation 2,4,10,15. Similarly, lumbar and pelvic manipulation has demonstrated improvement in patellofemoral pain syndrome9,16,19. Beyond manual therapy, evidence for the use of foot orthotics for various lower extremity injury as a preventative measure7 and as a method of treating PFPS 17.  However, the role of distal contributions, or more specifically excessive pronation, was recently questioned in a systematic review by Chuter and Janse de Jonge6. In their review, they proposed that a greater influence on lower extremity injury arises proximally from the “core”6. Regardless, what is evident in available research is that proximal and distance regions to the site of injury have some role either as a result of the injury, or as a precursor to the injury1,6,11,14.

Clinically, there are presentations and treatments related to regional interdependence which are a long way (if ever) from being able to be demonstrated or clearly explained in a research design. We are still in the early stages of understanding manual therapy, let alone regional interdependence. Bialosky, et al. (Open access link) provides a great review and proposed a model which encompasses both joint and soft tissue mobilization/manipulation 3.  Although the emphasis of this model and much of the research on manual therapy is based on a neurophysiological, peripheral, spinal, or supraspinal mediated mechanism 3, it is difficult to extrapolate whether these the neurological models also play a key role in regional interdependence. Perhaps now, with the treated “dysfunction” one or more joints away from the injury location, the importance of “movement”, as biomechanically dictated, plays a more important role? Or perhaps still, somewhere in “homunculus land”, a map of regional interdependence is now changed to alter both pain and movement patterns. It is too early to tell, but hopefully this question will soon answered! Whatever the mechanism may be, clinically, there still appears to be a degree of specificity and clinical reasoning necessary in order to provide an optimal outcome. To illustrate this, I want to present a brief clinical case.

This case involves a 23 year old male competitive soccer player who originally presented with posterior left rib pain around T5 region which somehow evolved into some form of left posterior shoulder pain and restricted ROM. Somatic dysfunctions for the thoracic spine, ribs, scapula, glenohumeral capsule, and surrounding tissue(including an incredibly tight latissimus dorsi) were identified. These factors were assumed to be key to recovering the 10-15 degree loss of shoulder flexion with a painful posterior “pinch” at the endrange. A gambit of joint mobilizations and attempts to lengthen the latissimus dorsi, as well as, various techniques for “releasing” other soft tissue restriction was started.  Despite 4 sessions of valiant attempts to regain this loss of shoulder flexion through manual therapy and stretching even up to two joints away, little progress was made. Out of shear randomness, I observed an obscurity in the way the inferior aspect of his rib cage moved when I passively flexed his left shoulder. Perhaps it was an illusion generated by my mind from years of staring at Thomas Meyer’s Anatomy Trains, but something made me believe it was worth looking at his rectus abdominis. Needless to say, simply palpating the rectus abdominis was enough to generate a startle response similar to a typical trigger point presentation. Tension and “restriction” was felt through the lateral band of the rectus abdominis. Much to the patient’s dismay, I spent two minutes “releasing” this restriction and without any other treatment. Immediately afterward, I was able to move him into those last 10-15 degrees of shoulder flexion pain free. One additional treatment was scheduled and the patient was set for a one week recheck, at which point they were still symptom free and discharged.

Looking back now, I could pretend I know what happened and propose a theory to explain it from a biomechanical model utilizing Anatomy trains. I could state that since the rectus abdominis inserts on ribs 5-7, it must then pull on the fascial origins of the pectoralis minor directly or through pulling the rib cage down. Consequently, the pec minor then pulls on the coracoid process of the scapula, which could  result in anterior tilting of the scapula, and therefore give a possible mechanical cause for the “pinching sensation” and  restricting shoulder flexion. The honest truth is, I don’t know why it worked, because it was such a random find. Yet oddly enough, it seemed as though I had to be specific enough in my treatment approach in order to get a positive outcome for this patient. Simply addressing classic restrictions around the shoulder was not enough in this case, I had to go even farther, and I had to use soft tissue! Did I truly decrease the tension in the rectus abdominis and therefore produce the mechanical cascade which lead to this resolution? Could it have been placebo, was the shear randomness of the treatment approach a psychological effect that somehow modulated the pain or ROM changes? I am completely open to any suggestions!

Clearly not every case needs to be this involved or complicated, and sometimes the area of injury is the best place to focus your treatment and leave it at that. At the same time, both clinical and research evidence seems to be paving way the importance of remembering that the leg bone is connected to the knee bone, and the knee bone connected to the thigh bone…

1. Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295-299. doi: 10.1016/j.math.2007.01.015.

2. Bergman GJ, Winters JC, van der Heijden GJ, Postema K, Meyboom-de Jong B. Groningen manipulation study. the effect of manipulation of the structures of the shoulder girdle as additional treatment for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms. design of a randomized controlled trial within a comprehensive prognostic cohort study. J Manipulative Physiol Ther. 2002;25(9):543-549. doi: 10.1067/mmt.2002.128373.

3. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther. 2009;14(5):531-538. doi: 10.1016/j.math.2008.09.001.

4. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-380. doi: 10.1016/j.math.2008.05.005.

5. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: A validation study. Ann Intern Med. 2004;141(12):920-928.

6. Chuter VH, Janse de Jonge XA. Proximal and distal contributions to lower extremity injury: A review of the literature. Gait Posture. 2012. doi: 10.1016/j.gaitpost.2012.02.001.

7. Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: A systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396-412. doi: 10.3113/FAI.2007.0396.

8. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976). 2002;27(24):2835-2843. doi: 10.1097/01.BRS.0000035681.33747.8D.

9. Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: Development of a clinical prediction rule. J Orthop Sports Phys Ther. 2008;38(6):297-309; discussion 309-12. doi: 10.2519/jospt.2008.2669.

10. Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: A single-arm trial. Phys Ther. 2010;90(1):26-42. doi: 10.2522/ptj.20090095.

11. Reiman MP, Weisbach PC, Glynn PE. The hips influence on low back pain: A distal link to a proximal problem. J Sport Rehabil. 2009;18(1):24-32.

12. Schellingerhout JM, Verhagen AP, Heymans MW, et al. Which subgroups of patients with non-specific neck pain are more likely to benefit from spinal manipulation therapy, physiotherapy, or usual care? Pain. 2008;139(3):670-680. doi: 10.1016/j.pain.2008.07.015.

13. Slater SL, Ford JJ, Richards MC, Taylor NF, Surkitt LD, Hahne AJ. The effectiveness of sub-group specific manual therapy for low back pain: A systematic review. Man Ther. 2012;17(3):201-212. doi: 10.1016/j.math.2012.01.006.

14. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12-19. doi: 10.2519/jospt.2009.2885.

15. Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230-236.

16. Vaughn DW. Isolated knee pain: A case report highlighting regional interdependence. J Orthop Sports Phys Ther. 2008;38(10):616-623. doi: 10.2519/jospt.2008.2759.

17. Vicenzino B, Collins N, Cleland J, McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: A preliminary determination. Br J Sports Med. 2010;44(12):862-866. doi: 10.1136/bjsm.2008.052613.

18. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658-660. doi: 10.2519/jospt.2007.0110.

19. Welsh C, Hanney WJ, Podschun L, Kolber MJ. Rehabilitation of a female dancer with patellofemoral pain syndrome: Applying concepts of regional interdependence in practice. N Am J Sports Phys Ther. 2010;5(2):85-97.