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Muscle Imbalance Evaluation and Treatment for the Low Back and Hip

AreasJose S. Figueroa, D. O.

Physical Medicine and Rehabilitation, NMM/OMM

AOCPM&R, Fall 2013

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Case Study

• In 1998 a 33 y/o gentleman presents with a 5 year history of right shoulder pain, which did not stop him functionally, but significantly affected his sleep.

• Diagnosed originally with biceps tendonitis, and given some OMM treatments with good but temporary relief.

• Dr. Greenman saw him and stated that he had a muscle imbalance…

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Objectives• Learn concepts of neuromuscular imbalances and their contribution to

chronic musculoskeletal dysfunction in the lumbar, pelvic and hip areas.• Learn the muscles that commonly affect the low back, pelvic and hip

areas.• Be introduced to the evaluation and treatment of muscle imbalances of

the lower quarter:– Evaluate Proprioception– Evaluate for the presence of faulty muscle “firing” patterns– Diagnose and manually treat tight/short muscles– Diagnose weak or pseudo-paretic muscles– Teach a home exercise prescription to address the tight/short and weak or

pseudoparetic muscles– Follow-up for re-evaluations and exercise adjustments– Teach patients how to self-treat certain common somatic dysfunctions

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Most of the information in this lecture is derived from the works

of

• Phillip Greenman, D.O.(he is the one in the pictures)

• Dr. Vladimir Janda, a specialist in rehabilitation medicine at the University of Charles, Prague, Czechoslovakia, deceased in 2006

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Road Map Muscle Imbalances• Muscles commonly affected by imbalances• Causes of Muscle Imbalances • Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: • Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short muscles• HEP for the weak or pseudoparetic muscles• Part Two

Muscle Balance

• The relationship between the strength and the length of the muscles around a joint or multiple joints.

• Ex. of muscles affecting one joint:– Vastus medialis obliquus (knee joint), soleus

(ankle) • Ex. of muscles Affecting multiple joints:

– Psoas (lumbar/SI/hip), hamstrings (knee/hip)

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Muscle Imbalance Theory• According to Dr. Janda, it is a malregulation by

the central nervous system (CNS) leading to:– Some muscles becoming tight– Some muscles becoming weak– Loss of control of integrated muscle function

• Loss of Symmetry and Control• Caused by some form of musculoskeletal

disturbance

Musculoskeletal Disturbance

• Can be caused by acute or chronic events. Examples include changes in lifestyle, or poor ergonomics, or trauma, or disease, etc.

• Examples: stress, participating in a poorly designed exercise program, sedentary lifestyle, joint and/or soft tissue disease or trauma, spending too much time working in front of a computer, loss of a limb, etc.

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Reflexes at the level of the:Premotor CortexMotor CortexBrainstemSpinal Cord1. Musculoskeletal

Disturbance

ArticularReceptors

Alpha Motor Neuron stimulates muscle fiber to contract.Gamma System: stimulates muscle spindle to adapt

Alteration in muscle tone, affecting joint position and function

Creation of Muscle Imbalances which maintain the wrong positions of the joints

MUSCLE IMBALANCE

CYCLE

Return to normal muscle tone

Addsto

affect

create

cause

create

resolves

remains

Understanding Motor Control• Movement: is performed by combined muscle

pull, which is very controlled in a very complicated manner– Controlled movements require many CNS signals

(afferent and efferent) with precise timing and number

• CNS controls movement through proprioception– It produces useful movements that adapt to our

constantly changing environment– Needs precise input from many receptors

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Sit Up Straight, Please

• Pelvic Clock• Helps to give you an awareness of the location

of the trunk when in postural balance• Used in the supine, seated and standing

postures• Let’s try the pelvic clock SEATED• Work on the Sit Stand Transfer, using

the pelvic clock

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Functional Disturbance• Injuries or diseases can cause muscles to react

differently than normal because of:– Guarding joints or organs– Inability to move properly due to tissue or nerve

damage• Chronic vs. Temporary:

– When the injury is chronic, the changes are longer lasting.

• Chronic poor posture re-trains the muscles in patterns of movements that eventually become incompatible with normal function

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Muscle Function Disturbance

• Chronic articular or muscle dysfunction feeds the afferent loop with more nociception and abnormal mechanoreceptor information, perpetuating ongoing aberrant muscle tone.

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Muscle Imbalances

• Some muscles become tight (tonic)• Some muscles become weak (phasic)• Altered motor control (impaired proprioception)

– Either muscles do not contract when they are supposed to, so they act as if they were weak

– Or muscles contract too early when moving certain joints or too much when maintaining certain postures

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Road Map Muscle Imbalances Muscles commonly affected by imbalances• Causes of Muscle Imbalances • Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: • Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short muscles• HEP for the weak or pseudoparetic muscles• Part Two

Functional Disturbance• There are two main ways that the muscles

react to functional disturbance: • Some muscles become tight/short

– Usually the slow twitch fiber type muscles

• Some muscles become weak (or pseudoparetic)– Usually the fast twitch fiber type muscles

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Slow-twitch Fiber Type

• Oxidative metabolism, high capillary density, greater endurance, characteristic red color

• Twitch speed is slow, making their function more tonic or postural

• Slow-twitch muscles react to functional disturbance by shortening and tightening.

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Fast-twitch Fiber Type

• Glycolytic metabolic pathway, fatigue rapidly, have low capillary density, whitish color.

• Twitch speed is fast and shorter lasting, making their function phasic.

• Fast-twitch muscles react to functional disturbance by weakening or becoming pseudoparetic

Table 1. Common upper and lower extremity muscles and

their reaction to injury

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Body Region Function: Primarily Postural/Tonic (Short and Tight)

Function: Primarily Phasic (Weak)

Pelvic and Hip Region

HamstringsIliopsoasRectus FemorisTensor Fascia LataThigh Adductors Piriformis

Vastus Medialis Obliq.Vastus LateralisGluteus Maximus Gluteus MediusGluteus Minimus

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Body Region Function: Primarily Postural/Tonic (Short and Tight)

Function: Primarily Phasic (Weak)

Leg GastrocnemiusSoleus

Tibialis AnteriorPeroneus

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Body Region Function: Primarily Postural/Tonic (Short and Tight)

Function: Primarily Phasic (Weak)

Neck and Trunk Erector Spinae Group -Lumbar Region -Cervical RegionQuadratus LumborumScalenesSternocleidomastoid

Deep Cervical Spine FlexorsErector Spinae muscles -Mid-thoracicRectus AbdominisExternal ObliquesInternal ObliquesTransversus Abdominis

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Body Region Function: Primarily Postural/Tonic (Short and Tight)

Function: Primarily Phasic (Weak)

Shoulder Girdle Pectoralis MajorLevator ScapulaeUpper TrapeziusBiceps BrachiiLatissimus Dorsi

Middle TrapeziusLower TrapeziusRhomboidsSupraspinatusInfraspinatusTriceps BrachiiSerratus AnteriorDeltoid

Stand Up, Please

• Static Active Stretch: muscle is put on a passive stretch with little to no movement, while its antagonist is being used to maintain the position of the muscle stretched and to reciprocally inhibit the muscle stretched. Examples:– Rectus Femoris– Chest stretch

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Road Map Muscle Imbalances Muscles commonly affected by imbalances Causes of Muscle Imbalances • Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: • Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short muscles• HEP for the weak or pseudoparetic muscles• Part Two

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Causes of Muscle Imbalance

• Noxious stimulus (due to acute or repetitive trauma, chronic injury, arthritis, space occupying lesion, neurologic injury, metabolic disease, loss of a limb, etc.)

• Prolonged postural disturbance (resulting in a prolonged alteration of the center of gravity, with mechanical responses requiring long term muscle adaptations)

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Causes of Muscle Imbalance

• Excessive physical demands (usually chronic overuse or under-use or chronic lack of rest-especially stage IV sleep)

• Emotional problems or other psychological factors (tightness and fatigue that result when we are "uptight" or stressed, anxious, depressed, etc.)

– We show emotion with our muscles– Muscular action tends to create and/or accentuate

emotion

Reflex Pathways are involved in maintaining muscle imbalances

• Co-Contraction:– Lumbar erector spinae and psoas contracting to stabilize an injured

lumbar spine: What would someone look like who has this?• Reciprocal Inhibition:

– Psoas tightening causing weakness of gluteus maximus– Pectorals tightening causing weakness of interscapular muscles

• Reciprocal Inhibition leading to Substitution– Hamstrings doing most of the hip extension instead of the gluteus

maximus• Still need to address the offending tight muscle: Iliopsoas

– Tensor fascia lata doing most of the hip abduction due to a weak gluteus medius / minimus

• Still need to address the offending tight muscle: Adductor

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Muscle Function Disturbance

• This vicious cycle can be interrupted and reprogrammed through• OMM• Specific Exercises prescribed in the Proper Sequence

• Thus, the overall muscle tone and balance can be returned to (and maintained in) a more normal state.

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Reflexes at the level of the:Premotor Cortex, Motor Cortex, BrainstemSpinal Cord

1. Musculoskeletal Disturbance

ArticularReceptors

Alpha Motor Neuron stimulates muscle fiber to contract.Gamma System: stimulates muscle spindle to adaptAlteration in

muscle tone, affecting joint position and function

Creation of Muscle Imbalances which maintain the wrong positions of the joints

MUSCLE IMBALANCE

CYCLE

Return to normal muscle tone

Addsto

affect

create

cause

create

resolves

remains

1. OMM2. Exercise Prescription

1. OMM2. Exercise Prescription

Re-Programming

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Functional Capacity!

• Despite the osseous pathology of his own lumbar spine, Dr. Greenman used to demonstrate all of the exercises in his text and to his patients.

• This demonstrates the functional capacity in the presence of significant osseous pathology.

• This demonstration was a powerful motivational tool.

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Kneel “Up” Straight, Please

• Pelvic Clock Kneeling• Floor: sit to kneeling transfer

– From knees fully bent to knees at 900 flexion• Kneeling to ½ kneeling maneuver

– One foot on the ground– The other foot with the ball of the foot on the

ground• ½ Kneeling to Stand transfer with or without

assistance

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Road Map Muscle Imbalances Muscles commonly affected by imbalances Causes of Muscle Imbalances Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: • Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short muscles• HEP for the weak or pseudoparetic muscles• Part Two

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Diagnosis of Muscle Imbalances Three Specific Types of Clinical Testing

• Evaluate Proprioception– Through balance testing

• Evaluate the sequence of muscle contraction (muscle “firing” patterns) during specific movements to evaluate which muscles contract out of sequence, acting as if they were weak

• Evaluate asymmetry in muscle lengths– Muscles are isolated as much as possible and then

tested for symmetry in their lengths and compared with estimations of normal

Treatment of Muscle Imbalances

General Principles:• Goal: restoration of proper muscle length, strength

and control of muscle function• Start with OMM• May need a home exercise prescription (HEP)• HEP should address muscle control (i.e.,

proprioception re-training)• When treating muscle imbalances: Quality of movement is

more important than quantity

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General Treatment Sequence

1. Establishing a process of re-evaluations to monitor progress

2. Establish a level of patient commitment to follow through

3. Re-training proprioception– home exercises (single leg stance)– PT (more advanced intervention)

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General Treatment Sequence4. Stretching the tight muscles

– manual stretches in the office (Dr. or PT)– home stretches (self-stretches)

5. Re-training or strengthening late contracting (pseudoparetic) or weak muscles

– home “strengthening” exercises6. Teaching the patient how to self-treat specific

recurring somatic dysfunctions on their own

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Road Map Muscle Imbalances Muscles commonly affected by imbalances Causes of Muscle Imbalances Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: Evaluate Proprioception• Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short muscles• HEP for the weak or pseudoparetic muscles• Part Two

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DIAGNOSIS AND TREATMENTS OF COMMON MUSCLE IMBALANCES

OF THE PELVIS AND LOW BACK

HANDS-ON SESSION

Treating Impaired Proprioception

• Retrain balance with bare feet on a carpeted surface in order to stimulate the propioceptors of the sole of the foot

• Practice “shortening the foot”-also stimulates the proprioceptors of the soles

• Goal: the capacity to symmetrically stand on one leg with arms crossed and eyes closed for 30 seconds– Do the best possible if unable to reach goal

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Look to your feet, Please

• Remove your shoes• See if you can shorten one of your feet now• Let’s test each other’s SINGLE LEG standing

balance

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Treating Impaired Proprioception

• Bilateral exercises that help increase proprioception and increased body awareness:– Walking, Swimming (may need mask/snorkel)– Properly taught Pilates– Bilateral Martial Arts movements like some of the

ones found in Tai Chi, Choi Kwang Do, etc.

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Road Map Muscle Imbalances Muscles commonly affected by imbalances Causes of Muscle Imbalances Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns• Diagnose and manually treat tight/short muscles• Home exercise prescription (HEP) for the tight/short muscles• HEP for the weak or pseudoparetic muscles• Part Two

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Evaluating Muscle Firing Patternsof

Lower Quarter Muscles

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PELVIC CLOCKS

• Three dimensional evaluation of function of the lumbar spine and pelvis.

• Used diagnostically and therapeutically.

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Testing: PELVIC CLOCKS

Clock Orientation Start Position

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Testing: PELVIC CLOCKS

12 O'clock 6 O’clock

Problems: pubic dysfunction, iliosacral dysfunction, sacral dysfunction (base posterior), lumbar extended dysfunction, tight psoas, tight paraspinals, weak abdominals

Problems: pubic dysfunction, iliosacral dysfunction, sacral dysfunction (base anterior), lumbar flexed dysfunction

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Testing: PELVIC CLOCKS

3 O’clock 9 O’clock

Problems: Lumbar rotation to the left, sacral torsion to the right , weak abdominal obliques, transversus abdominis

Problems: Lumbar rotation to the right, sacral torsion to the left, weak abdominal obliques, transversus abdominis

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Testing: HIP EXTENSION FIRING PATTERN

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Testing: HIP EXTENSION FIRING PATTERN

• Hamstrings.• Gluteus maximus.• Contralateral lumbar erector spinae (low).• Ipsilateral lumbar erector spinae (low).

• Contralateral lumbar erector spinae (high).• Ipsilateral lumbar erector spinae (high).

Significant finding is late firing of the gluteus maximus.

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Other Firing Patterns

• Hip Abduction Firing Pattern on Sidelying– Normal: Gluteus medius, Tensor fascia lata (TFL),

Quadratus lumborum (QL) and Erector Spinae– Abnormal: substitution with weakness of gluteus

medius and early firing of TFL (causing IR and flexion of the hip) and QL. Worst scenario is that the motion is initiated by the firing of the QL.

• Pelvic Tilt Heel Slide• Pelvic Tilt with Hip Abduction and External Rotation• Active Trunk Rotation

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Road Map Muscle Imbalances Muscles commonly affected by imbalances Causes of Muscle Imbalances Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles• HEP for the weak or pseudoparetic muscles• Part Two

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Evaluating and Treating Muscle Length Asymmetry

of Lower Quarter Muscles

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Stretching: PSOAS & RECTUS FEMORIS

Manual Stretching of Muscles

• Manual Stretching done at the clinic is very important because it can significantly increase the muscle lengths further than self-stretching alone can.– “Supercharges” the patient’s home stretching

routine• Sustained Stretch: 20-30 secs, 2 or 3 reps.• Muscle Energy: Post-isometric Relaxation and

Stretch57

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Stretching: RECTUS FEMORIS PRONE

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Stretching: PSOAS PRONE

• Anterior Hip Capsule Stretch

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SELF STRETCH: PSOAS

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SELF STRETCH: RECTUS FEMORIS

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Stretching: ADDUCTORS

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Stretching: ADDUCTORS (Long)

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Stretching: ADDUCTORS (Short)

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SELF STRETCH: ADDUCTORS

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Stretching: PIRIFORMIS

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Stretching: PIRIFORMIS

• Above 90 degrees

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Self Stretch: PIRIFORMIS

Above 90 degrees Below 90 degrees

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Self Stretch: PIRIFORMIS (Prone)

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Stretching: LATISSIMUS DORSI

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Stretching: LATISSIMUS DORSI

Manual Stretch

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Self Stretch: LATISSIMUS DORSI

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Road Map Muscle Imbalances Muscles commonly affected by imbalances Causes of Muscle Imbalances Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles• Part Two

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Strengthening / Retrainingof

Lower Quarter Muscles

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Strengthening/Retraining: GLUTEUS MAXIMUS

• Prone hip extension.• Bridging.

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Strengthening/Retraining: GLUTEUS MAXIMUS

1. Contract Gluteus. 2. Contract Gluteus & hold knee.

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Strengthening/Retraining: GLUTEUS MAXIMUS

3. Isometric hold. 4.Concentric contraction.

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Strengthening/Retraining: GLUTEUS MAXIMUS BRIDGING

1. Contract transversus abdominus or maintain a slight 12 o’clock pelvic tilt.

2. Use two legs to bridge and contract buttocks.

3. Single leg bridge.

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Strengthening/Retraining:GLUTEUS MAXIMUS BRIDGING

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Strengthening/Retraining: ABDOMINALS

• Sit backs.• Curl ups.• Supine leg slides with stable transversus or

posterior pelvic tilt.• Norwegian exercise.

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Strengthening/Retraining: ABDOMINALS

Transversus abdominusRectus abdominus

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Strengthening/Retraining: ABDOMINALS

• Oblique abdominals

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Strengthening/Retraining: ABDOMINALS Sit Backs

• Performed in three stages, arms in front, arms crossed, and hands behind neck.

• Maintain a lumbar lordosis throughout.• Strengthens transversus abdominus in

subconscious mode.• Strengthens abdominals in a lengthened

position.

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Strengthening/Retraining: ABDOMINALS Sit Backs

• Start position. Level one.

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Strengthening/Retraining: ABDOMINALS Sit Backs

• Level Two • Level Three

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Road Map Muscle Imbalances Muscles commonly affected by imbalances Causes of Muscle Imbalances Overview of Diagnosis and Treatment of Muscle Imbalances

Hands On Workshop: Evaluate Proprioception Evaluate for the presence of faulty muscle “firing” patterns Diagnose and manually treat tight/short muscles Home exercise prescription (HEP) for the tight/short muscles HEP for the weak or pseudoparetic muscles Part Two

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Pause shortly. Then move on to the second part of the program.

Questions??????????????