Furniture sliders are extremely inexpensive (less than $10 at Lowes) and extremely versatile. I was inspired by Ross from Ross Training to experiment with these tools. One of my favorite exercise progressions is a multi-planar single leg squat. The slider is a great cue to promote mobility and stability as well as adding flow to a sequence of movements. It easily allows progressions and regressions based on the needs of the individual.
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
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.
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.
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!
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.
I was originally going to do a little write-up on Vladmir Janda’s prone hip extension (PHE) test, but I found that Dr. Greg Lehman has already done a great job with the topic on his blog. As Dr. Lehman mentioned, we really don’t know what to take from this test from a research perspective. Clinically, many have seen that this test does demonstrate test-retest changes with a successful outcome in a treatment. In fact, I have observed a clinical example in which a patient with hip pain had been participating in numerous closed and open chain exercise interventions that involved hip extension and hip abduction to address their hip pain with no improvement. Yet, ultimately a single prone exercise which emphasized conscious effort to perform isometric gluteal contraction completely resolved her year long struggle with hip pain. Despite this clinical evidence, little research regarding injury and the gluteus maximus has been performed. I thought I’d do a quick blurb on some of the few studies which have shown some correlation between gluteus maximus activation and any injury.
Bullock-Saxton, Janda, and Bullock demonstrated a correlation between ankle sprain injury and an increased delay in gluteal activation2. Similarly, Bruno and Bagust demonstrated an increased delay in gluteal activation in low back pain (LBP)1. One concern with both of these studies were that they utilized the PHE test, in which Dr. Lehman already pointed out previous research showing inconsistencies in activation patterns including the relevance of the gluteus maximus delay. Further yet, since the PHE is performed in “prone”, we have remember, as Gary Gray likes to point out, everything changes once the foot hits the ground. Vogt and his team examined muscle activation patterns in both an LBP and asymptmatic population during walking. In their study, they demonstrated that both the gluteus maximus and the erector spinae were active for a prolonged period of time in an LBP population and that, oddly enough, the glut max fired earlier (although so did the erector spinae and hamstrings) in the gait cycle than the asymptomatic population5. Likewise, during standing extension from a full flexed position, Leinonen et al. demonstrated that in a LBP population, the glut max fired earlier than the erector spinae4. So wait, aren’t we trying to get the glutes to fire earlier as a result of our treatment, or possibly even longer, in the thought of protecting the spine? However, research seems to indicate the body is already trying to do it for us.
So here in lies our enigma regarding gluteus maximus activation and our beliefs regarding its role in musculoskeletal dysfunction. Clinically we’re seeing results with what we perceive to be our gluteal emphasized exercise prescriptions, but it might not be for the reasons we think. As Dr. Lehman mentioned, we may be looking at the wrong variable of gluteal function, perhaps it is peak amplitude or glute max endurance3? Or perhaps our treatments are effecting something else entirely, and simply performing a neuromuscular extensor pattern in the “region of dysfunction” is enough to get a therapeutic benefit (a good future blog topic!). Regardless, we need to be open to alternative explanations for the gluteus maximus enigma, in particular if those explanations come with improved outcomes.
1. Bruno PA, Bagust J. An investigation into motor pattern differences used during prone hip extension between subjects with and without low back pain. Clinical Chiropractic. 2007;10(2):68-80. doi: 10.1016/j.clch.2006.10.002.
2. Bullock-Saxton JE, Janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip extension. Int J Sports Med. 1994;15(6):330-334. doi: 10.1055/s-2007-1021069.
3. Kankaanpaa M, Taimela S, Laaksonen D, Hanninen O, Airaksinen O. Back and hip extensor fatigability in chronic low back pain patients and controls. Arch Phys Med Rehabil. 1998;79(4):412-417.
4. Leinonen V, Kankaanpää M, Airaksinen O, Hänninen O. Back and hip extensor activities during trunk flexion/extension: Effects of low back pain and rehabilitation. Arch Phys Med Rehabil. 2000;81(1):32-37. doi: 10.1016/S0003-9993(00)90218-1.
5. Vogt L, Pfeifer K, Banzer W. Neuromuscular control of walking with chronic low-back pain. Man Ther. 2003;8(1):21-28.