BY MAI-LINH DOVAN M.SC., CAT(C)Founder, Rehab-U | Movement & Performance TherapyCertified Athletic Therapist

COURSE MANUAL

Level - 2

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Movement Optimization

MovementOptimizationfor Prehaband Performance

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Functional rehabilitation Since completing Level 1 you’ve confidently helped your clients establish the fundamentals of movement. You have learned to build effective interventions focusing specifically on mobility, stability/motor control, patterning and sequencing. Once these fundamentals are restored, how do you as a coach or trainer bridge the gap from injury to performance? This is the next step to ensure you become an asset to your clients during their rehab process. Level 2 Movement Optimization for Prehab and Performance addresses the importance of strength in the continuum of care. This course focuses on rehab periodization to effectively manage load, drive progress, and maximize performance while still protecting injury. This is where you complete your journey towards becoming a Movement & Performance Therapy Specialist. As a coach, trainer, or health professional, you are part of the rehabilitation process because you are the person whose role remains to keep individuals moving better and getting stronger. An in depth understanding of the healing process and tissue response to loading is of great value to the rehab process, and even more so is the capacity to select safe and specific exercises to avoid both underloading healthy tissue/movements and overloading sensitive tissue/movements. The objective of this course is to provide you with the know-how to assess movement that is pain-triggering or that is detrimental to the rehab process in order to build interventions to effectively manage movement and load, drive progress, and maximize performance while protecting injury. Collaboration and Scope of Practice The information provided in this course should not be used as a substitute for, nor does it replace, professional health care advice, diagnosis, or treatment; nor should it be taken to be the practice or education of medical care. Each professional should adhere to the statutory and regulatory provisions of their respective scope of practice by maintaining an understanding of these provisions and responsibilities to contribute to the safety and welfare of the client.Additionally, each professional has the obligation and responsibility to act in accordance with the ideals and standards of their respective profession. One of our values at Rehab-U is that of collaboration. Wherever and whenever possible, we encourage you to work collaboratively with all of the professionals involved in the care of your clients to ensure their recovery and safe practice of physical activity.

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Covered in this course:

• Introduction to Functional Rehabilitation: Understanding injury and redefining rehabilitative exercise

• Robustness and Resilience: Load management and dose-response for tissue tolerance

• Diagnosis – Yay or Nay: Looking beyond the structure

• Evidence-based practice: Right choice, right time, right person

• Load Management - “Rehab is Training”: Strength in the continuum of care for optimal recovery and return to performance

• Movement and Pain: Cause or Effect? Managing motor adaptation to pain

• Pain Monitoring Model: Rating and managing the load response

• Rehab Periodization: Establishing the framework for effectively programming strength into the

continuum of care

• Isometrics and Eccentrics in Rehab: Defining their role and when to appreciate or depreciate their use

• Relevant Training Methods: Manipulating training methods and loading schemes to suit rehab

needs

• Rehab Programming for Specific Injuries: Current and in-depth review of treatment and programming for impingement syndromes, common tendinopathies and low back pain

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SECTION 1 – FUNDAMENTAL CONCEPTS OF FUNCTIONAL REHABILITATION 1.1 STRENGTH IN THE CONTINUUM OF CARE In Level 1 of this course, the main focus was on FUNDAMENTAL MOVEMENT OPTIMIZATION, focusing specifically on mobility, stability/motor control, patterning and sequencing. In Level 2, we dive into STRENGTH IN THE CONTINUUM OF CARE. How do we get our clients from injured to strong?

*Original author unknown

1.2 THE FUNDAMENTAL MOVEMENT OPTIMIZATION STRATEGY RECAP The Movement Optimization for Prehab and Performance Level 1 Course introduced the Fundamental Movement Optimization Strategy. This strategy involving a sequence of mobilization, activation and integration is designed to establish the fundamentals of movement, focusing specifically on mobility, stability/motor control, patterning and sequencing, or any other element that influences movement (for example, behavior and compensation). Below is a brief review of the 3 fundamental sequences in the Movement Optimization Strategy: MOBILIZATION The objective of the MOBILIZATION sequence is to "create space": to improve the individual's ability to move, to make more mobile, to improve the quality of the movement. It's about identifying and addressing factors that limit or present barriers to movement to set the stage for improvement. This may include several strategies based on the barriers that have been identified: -reduce muscle tension / improve soft-tissue integrity -improve the length-tension relationship of antagonistic pairs of muscles -downregulate facilitated muscles -optimize joint range of motion in adjacent regions -improve dissociation capacity

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-promote proximal stability for distal mobility -create stability for better joint centration

ACTIVATION The objective of the ACTIVATION sequence is to "create awareness", which is used to: improve motor recruitment, improve mind-muscle connection. It is about identifying and addressing factors that contribute to or can facilitate movement.

This may include several strategies based on the barriers that have been identified:

-upregulate inhibited muscles

-improve the capacity to recruit and contract specific muscles or groups of muscles

-improve joint dissociation capacity

-promote proximal stability for distal mobility

Isolation exercises can work well in this sequence, as do isometrics. Isometric contractions produce higher levels of activation when compared to concentric and eccentric contractions and can improve the capacity to recruit muscles (even in dynamic actions). INTEGRATION The objective of the INTEGRATION sequence is to “create behavior” to gradually challenge the newly established length-tension or agonist-antagonist relationship and incorporate proper mobility and activation into more complex, coordinated movement. Here, we are concerned with sequencing and patterning of movement. The goal is to maintain positioning during a specific exercise or movement under load. This is the subtle difference, for example, between isolating and understanding hip extension (activation) and being able to use this hip extension in a squat, deadlift, lunge, etc. (integration), that is to say having the right movement pattern (repatterning). It is also about identifying and addressing behaviors that need to be controlled, modified, or improved.

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An emphasis on slow eccentrics can be an excellent tool in this sequence for two main reasons:

1) Cortical activity for movement preparation and execution has been shown to be greater during eccentric actions than concentric actions

2) In the case where pain has changed the way the individual moves, eccentric exercise (particularly

externally paced exercise) can decrease cortical inhibition.

3) Eccentric movements are more difficult to control and greater voluntary effort of required to perform a motor task that is more difficult to control. Eccentric exercise may improve neuromuscular control by targeting specific motor pathways in the brain.

1.3 UNDERSTANDING THE INJURY PROCESS Robustness and Resilience We often hear the terms "robust" and "resilient" used interchangeably. Both are important from a rehabilitation perspective. A tissue that is not robust will break more easily, as will a tissue that is not resilient. A robust tissue can tolerate more load without deformation. It can tolerate higher loads without giving. Think of a bullet bouncing off a bulletproof window. From a training perspective, think of the body’s ability to handle high loads. We will see how strength is important in ensuring robustness.

A resilient tissue can bend without breaking. It can tolerate deformation and return to its function unscathed. Think of a palm tree bending with the wind and standing straight on a windless day. From a training perspective, think of the body’s ability to handle loads applied differently. We will see how movement variability is an important component of resilience.

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Structure and tissues adapt to physical stress, or if we're speaking in training-specific terms, mechanical load, by a process called mechanotransduction. We are used to utilizing this process for muscles: stress the muscle to stimulate adaptations that promote muscle growth. Although they seem more "passive" than muscles, bones, tendons and ligaments, as well as cartilage are constantly and dynamically trying to adapt to their conditions. Contrary to muscles, meaningful results may take many more months or even years, but they are ongoing, which means they need to be addressed ongoingly as well. Musculoskeletal injury occurs through exposure to physical stress and is dependent on the magnitude and time of application of that stress. Excessive physical stress causes injury through any of the following 3 mechanisms: 1) A high-magnitude stress applied for a brief period (acute injury such as a sprain, strain or fracture)

2) A low-magnitude stress applied for a long duration

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3) A moderate magnitude stress applied to the tissue many times

*Images from National Spine Health Foundation

1.4 DIAGNOSIS: LOOKING BEYOND THE STRUCTURE

It is important to understand the different manifestations of ‘injury” because the terms “injured” and “in pain” do not necessarily mean the same thing.

“…after an injury tissues heal, but muscles learn. They readily develop habits of guarding that outlast the injury.”

-Dr. Janet Travell Pathology: We typically use the term pathology to identify a disruption in structure or function. These disruptions typically constitute a disease or diagnosis. Impairment: An impairment refers to a loss of function, for example, decreased range of motion, decreased strength. Dysfunction: The term dysfunction is commonly used to describe an impairment in function, which may involve range of motion, strength or other movement-related factors. Functional limitation: Refers to an activity that is limited due to pathology, pain or behavior. These can be activities of daily living (ADLs), sporting or recreational activities and/or any other specific activities.

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Diagnosis-specific vs diagnosis-inclusive Sue Falsone is an American athletic trainer; the first female athletic trainer to work in major American professional sports – she was the head AT for the LA Dodgers. In her book Bridging the Gap from Rehab to Performance, she makes a distinction between diagnosis-specific treatment and diagnosis-inclusive treatment. For the sake of simplicity, we will only briefly resume the terms. The diagnosis-specific treatment, or segment of the treatment, is based on the structural diagnosis. For example, how is shoulder bursitis treated vs chronic shoulder tendinopathy or a herniated disc vs spondylolisthesis. The diagnosis-inclusive treatment, while it takes into consideration the diagnosis, is not focused on the structure, but on overall function. Diagnosis-inclusive interventions, while they need to be specifically selected to protect the injured tissue, are not necessarily specific to the injured tissue. In Level 1, we assess and address the fundamental function of the shoulder and hip complex to ensure optimal movement for optimal performance capacity. We look at restoring scapular function for the shoulder complex and lumbopelvic function for the hip complex. We also assess and address other factors that can affect movement like the feet and breathing. Level 2 brings us into the realm of functional rehabilitation. It is still about restoring function to set the stage for optimal movement. But it is also about understanding injury, restoring pain-free movement and ensuring strength in the continuum of care.

“The Tyranny of Diagnosis” I encourage you to read this article by C.E. Rosenberg. For most of us, establishing the diagnosis has always been the first step to patient care. What are the signs and symptoms, what tests and imaging are most appropriate and then, based on the diagnosis, what predetermined therapeutic interventions are most appropriate. In musculoskeletal health, there has been a recent “movement” (pardon the pun) regarding the necessity of diagnostics and the negative effects of patients “becoming” their diagnosis. Even the correlation between structural diagnosis (or damage) and symptoms has been challenged. Although this has become a popular topic of late, it is not new ground for me. Along my career path, I have worked as a disability case manager and functional rehabilitation specialist. I remember attending a conference in the early 2000’s given by an orthopedic surgeon who presented us with imaging of 2 different people of the same age with a very similar extent of degenerative disc disease. He explained that one was one total disability (from a sedentary job) and the other, a highly competitive athlete. There are many more examples of such findings: “The prevalence of (hip) labrum tears is 62% in symptomatic subjects and 54% in asymptomatic subjects.” -Heery et al., 2018 “The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals.” -Brinjikji et al., 2015 “In a group of pain-free overhead athletes, 40% of dominant shoulders had rotator cuff tears. These athletes remained pain-free for five years after the study.” -Connor et al., 2003 The question we need to ask ourselves is: “How is knowing that there is a labral tear/disc degeneration/rotator cuff tear going to change my movement-based intervention”?

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1.5 EVIDENCE-BASED PRACTICE

It is difficult to clearly define evidence-based practice, rather, it is the integration of the three components presented in the figure above: clinical expertise, external scientific evidence and client perspectives. Essentially, evidence-based practice requires an understanding of the best available research evidence, practical experience, and understanding the patient/client. While the individual pieces of evidence-based practice seem clear, the actual process is more uncertain and frequently no “correct” or “best” intervention exists. The most difficult thing to share in education is the actual practice: how to put the pieces together. Each of these three components have their own definitions, of which you can find several: Research evidence: -empirical observation about the apparent relationship between events -data that has analyzed, sorted, displayed and communicated -information, facts or data supporting (or contradicting) a claim, assumption or hypothesis Clinical expertise: -combination of practical and theoretical knowledge -accumulated wisdom from experience -judicious application of research findings in the patient/client context Client perspectives: -client attitudes, beliefs, values, preferences -client expectations and motivations -client history, past experience

Dr. Karel Lewit, a neurologist who was part of the Prague School of Rehabilitation (along with Vladmir Janda whose theories we saw in the Level 1 course) is famed for stating that “we work at a level of

acceptable uncertainty”.

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1.6 LOAD MANAGEMENT

Rehab is training

“Rehab is Training” is our primary vision at Rehab-U | Movement & Performance Therapy. What we mean when we say that is that the same principles that apply for training need to apply for effective rehabilitation programming, from the clinic to the gym. We know that loading tissues creates a predictable response within a predictable range:

• stress on normal tissue within physiological limits and with sufficient recovery normally leads to tissue adaptation

• underloading tissues, such as via immobilization following injury or by decreased movement variability, results in very little tissue adaptation and decreased tissue tolerance

• if overload is excessive, repetitive or biomechanically inefficient, or of recovery is insufficient, we exceed the biological limit of the tissue and injury occurs

In understanding the injury process, we look at the different injury mechanisms, where stress was too great, too repetitive, or too sustained. If we can control the magnitude of the stress and the frequency of application, allowing sufficient recovery time, we get optimal loading:

Given this, load management is the most effective rehabilitation intervention. Load management can also be seen as activity modification, and as such, the same principles that apply to training apply to rehab. Rehab and training are therefore not two different entities, but part of a continuum.

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Therapeutic exercise should begin as soon as possible, which is as soon as it can occur without aggravating the injury. Rehabilitative exercises are specifically concerned with restoring normal function following injury, but strength exercises should also be included. The idea behind Rehab is training is to consistently select work within a range of effective dose-response that allows for maximal stress to avoid underloading healthy tissues while still protecting injured tissues.

This is achieved by an in-depth analysis to:

• identify loads, movements and postures that are pain-triggering to prevent ongoing irritation of

sensitive or sensitized structures

• identify pain-free loads, movements and postures that have the potential to load uninjured tissue without over-exposing injured tissue

• identify loads, movements and postures that can load the injured tissue without exceeding its

tolerance It is also imperative to understand how different positions, grips, levers, moment arms, etc. can impact movement so that at all times you can minimize compensation and maximize performance. Other considerations:

• It is important to understand the various phases of healing. Anything that is done in a rehabilitation program that interferes with the healing process will delay rehabilitation and progress. Some injuries and/or surgeries come with movement contraindications that also need to be respected to ensure the injured or repaired structure has had the time to adapt. Even without specific contraindications, the stresses of selected exercises must not be so great as to exacerbate the injured structure.

• When a joint or muscle is injured, normal function is compromised. Being able to assess and recognize compensation is key to re-establishing function. A solid understanding of biomechanics and functional anatomy is also essential in selecting and prescribing exercises that respect contraindications, limitations or restrictions throughout the rehab process. For example, can using a supinated grip vs a pronated grip be beneficial for a client struggling with rotator cuff tendinopathy

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SECTION 2 – MOVEMENT AND PAIN: CAUSE OR EFFECT? 2.1 PAIN EXPERIENCE & MOTOR ADAPTATION TO PAIN The pain experience The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The study of pain has identified many subjective components to pain, namely past experience. While it is a sensation that may come from several parts of the body, it is always unpleasant, and is therefore an emotional experience. Interestingly, Melzack and Casey (1968) proposed that the pain experience has three dimensions. It is beyond the scope of this course to provide an in-depth explanation of these but understanding them is important. The three dimensions can be briefly described as follows: Sensory-discriminative dimension: identifies the location on or within the body and the characteristics (mechanical, chemical and heat, among others) of the pain, and prompts the response to prevent or limit tissue damage. Affective-motivational dimension: is associated with the emotions related to pain and engages behaviors related to recovering from pain. Cognitive-evaluative dimension: considers the consequences and meanings of pain such as pain apprehension, anticipation of pain, catastrophizing, previous experience, etc. Motor adaptation to pain Many studies have shown that pain may alter movement, although the underlying mechanisms of this behavior are not quite fully understood. While some aspects of motor adaptation to pain are consistent, changes in behavior are unique to the individual and possibly to the muscles and/or tasks. This must be accounted for in theory, but more importantly from a rehab perspective, in the way in which we set up our interventions. There are several proposed mechanisms by which pain changes the way we move, that are effective at protecting from further injury, but come with consequences.

• Recent studies have shown that adaptation to pain involves a redistribution of activity within and between muscles. New motor neurons are recruited during pain, which may be a strategy to preferentially activate muscle fibers with different angles and attachments. This new net force direction would change the direction of contraction and the consequent load distribution on the painful structure.

• The redistribution of activity between muscles changes the mechanics of movement. While the gross outcome is maintained, the quality is affected, such as modified movement and stiffness. In the long term, modified load, decreased movement and variability may have detrimental effects.

• The redistribution of activity within and between muscles and the altered mechanics of movement serve to protect the body from pain and/or further injury. This adaptation would also be expected with the threat of pain or injury, even in the absence of pain or injury, an important point to remember when dealing with individuals with unhealthy attitudes about pain.

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2.2 MOVEMENT OPTIMIZATION AND PAIN Pain is a stimulus to change movement to protect injury or the painful tissue. This is a normal and efficient response. Unfortunately, the resolution of pain does not allow the individual to resume the initial, non-pain state patterns, for reasons described in the previous section on the pain experience and motor adaptation to pain. The Movement Optimization Strategy can be effectively applied to address the multiple adaptations and consequences of pain on movement:

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2.3 PAIN AND THE LOAD RESPONSE

*Pain-monitoring model (K. Silbernagel) (R. Thomée)

The pain monitoring model, originally described by Thomée and further utilized by Silbernagel, is consistently used in the literature as a guideline for monitoring continued use of activity during rehab for tendinopathy. Pain reported up to a level of 2 is deemed "safe" and exercises are allowed to be continued.

Pain up to a level of 5 is deemed “acceptable” but should be monitored. All pain should have subsided within 24 hours. If pain has not subsided, exercises must be modified to reduce stress either by manipulating volume, intensity, frequency and/or duration.

Pain above a level of 5 is considered “high risk’. Exercises should be stopped until pain has settled and then resumed. Depending on the number of days for pain to settle, exercises may need to be regressed (see Classification Schema).

Using this model allows clients to continue their participation in activity and allows you to monitor the progression of load using the pain monitoring system.

Silbernagel and Crossley further developed this using the Classification Schema above to monitor pain during the activity, pain the next day, the client’s perceived tendon strength and recovery days needed between activities.

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SECTION 3 – ESTABLISHING THE FRAMEWORK FOR REHAB PERIODIZATION

3.1 REHAB AND TRAINING PERIODIZATION

Strength in the continuum of care means that we should ensure that we maintain sufficient training intensities throughout the rehab process. The best way to do this is to periodize rehabilitation the same way we would periodize training. The rationale which mediates this choice is the premise that specific training workloads integrated into a systematic process will more likely produce sufficient stimuli for remarkable gains.

Just like with training, the objective of a rehab plan is to induce specific adaptations and then translate those adaptations into increases in performance, whatever that performance may be. A common problem with rehab programs based solely on corrective, therapeutic, or rehabilitative exercises, is that these exercises do not provide a stimulus great enough to induce an adaptation.

Rehabilitation programs are traditionally conceptualized in 3 phases which are based on the 3 stages of tissue healing: acute injury phase, repair phase, and remodeling phase. A couple of significant drawbacks to this approach are that the focus is solely on raising the physical tolerance (or biological limit) of the injured tissue and that the process is more of a standalone one instead of being integrated into a training periodization.

Instead, I propose merging this approach with traditional concepts of training periodization, manipulating methods, means and rep/loading schemes to meet the objectives of the rehab process.

We will approach our rehab periodization model with the 3 phases representing 3 mesocyles of 3-4 weeks:

Phase I –Tissue Healing and Movement Restoration

Phase II – Accumulation

Phase III – Intensification

3.2 PHASE I – TISSUE HEALING AND MOVEMENT RESTORATION

With acute tissue injury, the process of healing begins immediately following the injury. There is a cascade of cellular events following injury that initiate the inflammatory response, which is a critical to the healing process. This initial response lasts 2-4 days, and usually requires that the individual engage in very minimal activity. The repair phase begins a few hours after injury and last up to 4 to 6 weeks. It is characterized by the synthesis of a collagen matrix at the wound site. Care must be taken to progressively apply tensile stress to the collagen fibers without exceeding their mechanical limitations.

Injury to articular structures changes fundamental movement. Joint mechanoreceptors are damaged which results in deafferentation: disruption on the sensory feedback necessary for reflexive joint stabilization and neuromuscular coordination. As we saw in the Level 1 course, injury to the shoulder complex or the upper extremity typically disrupts scapulothoracic function and injury to the hip complex or lower extremity typically disrupts lumbopelvic hip function.

Muscle activation is also affected by injury. Arthrogenic inhibition is an ongoing reflex inhibition of musculature surrounding a joint following injury to structures of that joint. In simple terms, arthrogenic inhibition is a reduction in motor neuron pool recruitment. This inhibition decreases the ability of recruitment within the motor neuron pool. This is why specific, isolated muscle activation exercises are an important part of the rehab process.

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Proprioception is also an important element of neuromuscular control. Closed-kinetic-chain exercises create axial loads that stimulate articular mechanoreceptors, while open-kinetic-chain exercises require more conscious awareness of limb position. Mechanoreceptors in the foot provide feedback that can affect positioning and posture.

As we have seen from the previous discussion on movement adaptation to pain, pain and injury change the way people move. As such, even in the absence of an acute tissue injury, anyone who has pain or has had pain will being at Phase I.

Main objectives:

• decrease pain and promote healing • restore fundamental movement capacity • re-establish neuromuscular control • facilitate afferent pathways (prioprioception) • address arthrogenic muscular inhibition

Main strength quality: Hypertrophy

• low training intensities • protein synthesis • activation of satellite cells to facilitate repair and rebuilding

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3.3 PHASE II - ACCUMULATION

In training periodization, the objective of the accumulation phase is to stimulate neuromuscular adaptations through volume to improve work capacity. This phase is characterized by higher volume and lower intensities, which is essentially a great fit for a rehab process, where the capacity to work at high intensity is limited.

The goal is to promote significant structural (hypertrophy, tendon strength) and neuromuscular changes (inter/intramuscular coordination, cortical inhibition)

Main objectives:

• build work capacity/load tolerance/strength-endurance • increase muscle mass and tendon integrity • accumulate stress to increase stress tolerance (improve resilience)

Main strength quality: Functional hypertrophy

• upper end of functional hypertrophy for moderate training intensities • improve intramuscular coordination (capacity to recruit more motor units within a muscle) • improve intermuscular coordination (capacity to use different muscles in conjunction to perform a

lift) • decrease cortical inhibition

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3.4 PHASE III - INTENSIFICATION

Intensification phases stimulate neuromuscular adaptations through intensity. This improves motor unit recruitment and facilitates the development of strength. This phase is characterized by lower volume and higher intensities.

The objective is to re-introduce strength work while manipulating rep/loading schemes to prevent compensation or breakdown of form. Remember: A robust tissue can tolerate more load without deformation. It can tolerate higher loads without giving.

Main objectives:

• promote specific direct loading/strength work • reinforce dynamic stability

Main strength quality: Strength

• higher intensities • more complex rep schemes based on training age and/or as phase progresses

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SECTION 4 – THE POWER OF ISOMETRICS AND ECCENTRICS IN REHABILITATION 4.1 ISOMETRICS Hypoalgesic effects: Exercise-induced hypoalgesia is a well-documented phenomenon: acute exercise reduces sensitivity to painful stimuli.

• In their meta-analysis, Naugle, Fillingim, and Riley (2012) found that isometric exercisereduced pain perception across all pain stimuli (experimentally-induced noxious stimuli) and exercise protocols (with the exception of one study included in the metanalysis)

• Many studies have shown that submaximal isometric contractions engage a centralized pain

inhibitory response The optimal dose of exercise that is needed to produce hypoalgesia is not well-documented, and there is some variation in findings of studies to date:

• Some studies have shown that long-duration, low-intensity (25% of MVC) contractions have the

greatest analgesic effect, however, contractions of up to 80% have shown analgesic effects

• Holding the amplitude of a contraction constant at 25% of MVC and varying its duration between 1, 3, and 5 minutes does not alter the magnitude of the analgesic effect, although each condition is effective in reducing the perception of pain

• Other observations show that the amplitude and duration of thecontraction do alter pain perception, with 25% of MVC contractions to task failure leading to significant analgesic effects, whereas contractions at 25% of MVC for 2 minutes do not. This finding suggests that the recruitment of high threshold motor units is necessary for the analgesic effect to emerge, and that increasing force amplitude in acute tasks is not effective in reducing pain perception, but task failure is

• Other evidence suggests that the recruitment of high threshold motor units is not necessary for analgesic effects to emerge. For instance, reductions in pain perception have been demonstrated during and following shorter contractions in the range of 15 to 120s

Since there is no consensus on optimal dosage of isometric exercise for hypoalgesia, we advocate individualization based on the limiting factor:

• If there is still residual pain that limits the intensity of contraction that is possible, opt for low-intensity, long-duration isometrics

• If pain limits the individual from holding the contraction for a longer duration, opt for higher intensity, lower-duration isometrics

• If the individual is deconditioned, for example following a period of immobilization or disuse, they may not be able to produce high force nor hold for long durations. Opt for as hard as possible as long as possible

There really is no right or wrong, as long as you have a reason for the parameters you are applying!!! Neuromuscular effects:

• A study by Babault et al., 2001 showed that voluntary muscle activation was 88.3% and 89.7% for maximal eccentric and concentric contractions, respectively, and 95.2% for maximal isometric contractions.

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• A majority of studies have also concluded that human subjects can maximally or near maximally (voluntary activation 95%) activate their muscles during maximal voluntary isometric contractions

Effects on strength:

• Isometric contractions can help improve strength at a specific point in the range of motion

• Because isometrics are not as energy expensive as other forms of contractions, they can be used frequently and are therefore quite useful for re-patterning/re-programming

Additional considerations:

• when range of motion is irritable or a short period of immobilization is required, isometrics contractions can be used to maintain activation

• Static positioning of isometric action helps mitigate movement error or rep to rep variability 4.2 ECCENTRICS Neuromuscular effects

• Cortical activity for movement preparation and execution has been shown to be greater during eccentric actions than concentric actions

• Not only has the intensity of cortical signals been shown to be higher for controlling eccentric muscle actions, but also the area of the brain involved. This may indicate the involvement of more functional regions in the brain

• The muscle spindle, which normally causes a reflexive contraction of the muscle during lengthening is inhibited to allow for an eccentric contraction to occur, thereby increasing cortical drive to the muscle. This inhibited spinal mechanism is thought to increase the need for movement preparation and motor control.

• Eccentric movements are more difficult to control and greater voluntary effort of required to perform a motor task that is more difficult to control. Eccentric exercise may improve neuromuscular control by targeting specific motor pathways in the brain.

• It is proposed that muscles adapt acutely to eccentric exercise by changing optimal length

allowing muscle fibers to operate at longer lengths while avoiding the descending limb of the length-tension curve (targeted muscle becomes more compliant to strain due to the addition of sarcomeres in series)

• Eccentric training is associated with changes to the myotendinous junction: tendon hypertrophy and stiffening.

Effects on strength:

• Eccentric training yields more strength gains. Eccentric-only training has been shown to yield great total maximal strength improvements when compared to concentric-only training

• High-force eccentric training results in increased muscle-tendon stiffness, greater force at failure and an improved ability to absorb energy at the musculotendinous junction

Additional considerations:

• Because much greater force can be produced eccentrically than isometrically or concentrically (2-3 x greater), we can overload tissues to a greater extent

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SECTION 5 - MANIPULATING TRAINING METHODS AND LOADING SCHEMES FOR REHAB NEEDS 5.1 ISOMETRIC AND ECCENTRIC METHODS OVERCOMING/YIELDING ISOMETRICS Yielding: holding a weight at a certain position in the range of motion Overcoming: pushing/pulling against an immovable external resistance EXTERNALLY PACED EXERCISE Movement mechanics are influenced by motor control changes that contribute to muscle activation. Decreased movement variability has been observed in tendinopathy, and aberrant tendon load from altered motor control is thought to lead to load accumulation in a specific region. Externally paced training, such as a metronome-paced tempo, has been shown to increase drive to the muscle, increase movement variability and decrease cortical inhibition. LOADED STRETCHING The basic concept of loaded stretching is contracting a muscle while it is in a stretched position. The goal is to become efficient at contracting a muscle in an elongated position or allowing a muscle to function more optimally in an elongated position. Essentially, it is a yielding isometric performed at the bottom of a lift which over time becomes a super slow eccentric. General parameters are to aim for a total of 3 minutes (modify as needed) under load and get there in as little total time as possible, that is, as few sets as possible. PAUSE REPS The strategic use of pauses can help develop strength specific parts of the range of motion and/or in key positions. They also allow a pause to focus on positioning and lifting mechanics. Pauses during the concentric action interrupt the momentum of the lift and force you to overcome inertia a second time and are very good for strength. Pauses during the eccentric action are useful for hypertrophy and motor control. TEMPO CONTRAST Tempo contrast consist of intra-set variations in tempo. For example, performing 2 very slow reps, 2 regular speed reps, 2 slow reps, etc. Typically used as a hypertrophy method, it recruits more muscle fibers due to the different types of rep contractions. It can be very useful in rehab not only for muscle recruitment, but to re-establish control. Because it is more neurally demanding, is can also address cortical inhibition much like externally paced exercise.

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5.2 LOADING SCHEMES STANDARD SETS The bulk of your program should be built using standard sets. These are especially important in the earlier rehab phases, but even in later phases, there is no need to have a high variation of loading schemes between exercises. Standard sets consist of performing the same number of reps in each set. CLUSTERS There are technically 2 different types of clusters: 3/1/1/1 using 5RM (85%) and 1/1/1/1/1 using 3RM (90%). The 10-15 second rest between reps allows to replenish ATP-CP and lift the load again. This rep scheme allows you to perform more reps than what you would normally be able to do in a standard set and is used to develop strength. *TECHNIQUE CLUSTERS Technique clusters are a variation of clusters that are essentially extended sets of singles: set up – execute – rest – reset. You can use a set and rep scheme or have the client perform 1 rep every 10 or 15 seconds for a specific amount of time. The objective is to recreate the proper positioning over and over again, with enough rest between sets to avoid fatigue and compensation. You will use higher reps and lower intensity versus the traditional cluster. DESCENDING REPS The reps decrease and intensity increases from set to set. Descending reps can be useful in the rehab process to progressively build up intensity. Example: 12, 10, 8, 6. BACK OFF SETS Back off sets are an extension of descending reps. At the end of a descending set, you back off to a final lower intensity set. This is useful to start to introduce higher intensity, but the final set creates a volume response to include a hypertrophy component. Example: 12, 10, 8, 6, 15. STAGE SYSTEM DESCENDING Stage descending sets are based on the law of repeated effort. Simply defined, repeated efforts lead to an increase in communication strength between the nervous system and muscular system. The more the effort is repeated, the more efficient the pattern becomes. Stage descending sets can be useful in the rehab process to repeat and integrate movement. Each set is repeated twice and then intensity is increased. Example: 9, 9, 7, 7, 5, 5.

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SECTION 6 - UNDERSTANDING TENDINOPATHY 6.1 TENDINOPATHY: RELEVANT CLINCAL INFORMATION Tendinopathy is an umbrella term that indicates a non-rupture injury of the tendon that is exacerbated by mechanical loading. It is often described as a failed healing response. When you overload a healthy tendon, you move it from a healthy state to an injured stated, much like when you train a muscle. However, without appropriate recovery, the tendon cell stays metabolically primed and reacts to minimal activity, starting the cycle of failed healing. There is considerable research around tendinopathy, the most recent of which revolves around inflammatory versus degenerative tendinopathy. The most widely accepted model of this is that of Cook and Purdam (2009) who proposed a continuum of pathology from reactive tendinopathy/early tendon disrepair to late tendon dysrepair/degenerative tendinopathy:

*Cook and Purdam (2008) Reactive tendinopathy typically results from acute tensile or compression overload. Note that this response is an acute, short-term adaptation to overload that occurs that reduces stress and increases stiffness. If sufficient time is allowed between loading sessions, the tendon has the potential to revert to normal. Look for the following in your history-taking: -unaccustomed physical activity -change in volume or frequency of training -excessive repetition of a particular movement or skill -other injury that may result in a change in the way the individual is moving -insufficient recovery between sessions or specific movements that overload the tendon

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The frequency, volume or length of time over which load has been applied are important variables. Late tendon dysrepair/degenerative tendinopathy is primarily seen in a chronically over-loaded tendon, so it is usually typical of the older athlete, but can be seen in younger or elite athletes with a chronically over-loaded tendon. 6.2 LOAD MANAGEMENT FOR TENDINOPATHY Recent studies have shown that compression may play a role in tendinopathy. Specifically, the combination of compressive and tensile loads on the tendon can be particularly damaging. The most important part of load management is reducing both tensile and compressive load. While people have typically been instructed to stretch as part of treatment for tendinopathy, most stretches result in a compressive load on the tendon and should actually be avoided. If muscle length is an issue that needs to be addressed, it is preferable to default to other soft-tissue modalities such as foam rolling, self-massage, etc. at the bulk of the muscle while avoiding pressure over the tendon area. Contrary to the popular rehab approach to tendinopathy, eccentric loading is not always well-tolerated, at least not early on in the rehab process. However, an eccentric emphasis using non-offensive loads, positions or postures can be helpful. Low-velocity, high–tensile loads typical of muscle hypertrophy programs have been shown to produce beneficial effects on tendon structure. Generally, tendon loading without energy storage and release is well-tolerated. Defaulting to these types of exercises avoids underloading tissues. Managing the offending load may vary from allowing a few days between high tendon loads (tendon loading with energy storage and release) to removing these altogether. In the short term there will be a net loss of collagen production for around 24-36 hours post exercise – so allow adequate rest days between strength sessions. High tendon loading is associated with up to 72 hours of decreased collagen production, so consider allowing 2-3 days between training sessions according to the Phase.

“The joint that travels the most gets the most amount of stimulus.

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SECTION 8 – PERIODIZATION FOR PATELLOFEMORAL TENDINOPATHY 8.1 ANATOMY AND FUNCTION OF THE EXTENSOR MECHANISM

The patellar tendon is a continuation of the quadriceps tendon that attaches the infrapatellar pole to the tibial tuberosity. We often refer to the quadriceps and patellar tendons individually but in reality, they are a continuous, anatomic tendon entity. The formation of the patella embryologically appears to separate the tendon into these two parts. The function of the patella in the knee extensor mechanism is to increase the mechanical advantage of the quadriceps. It does this by increasing the angle of pull of quadriceps on the tibia during the last 30 degrees of extension, because it essentially holds the quadriceps tendon away from the axis of movement. The line of pull from the quadriceps and patellar tendons causes a resultant compressive force that increases as knee flexion angle increases. This is true even with passive knee flexion. With quadriceps contraction, the compressive force increases additionally. Forces applied to PF joint: Walking ½ x BW Stair descending 5 x BW Squatting 7 x BW Deep squatting 20 x BW

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SECTION 9 – PERIODIZATION FOR HIP IMPINGEMENT 9.1 HIP IMPINGEMENT: RELEVANT CLINICAL INFORMATION There can be many different causes for anterior hip pain. Some examples are femoroacetabular impingement (FAI), labral pathology, chondral pathology, osteoarthritis, femoral anterior glide syndrome and hip joint laxity. Impingement is one of the common causes of anterior hip pain. Much like with the shoulder, the hip is commonly placed in a position ofimpingement in athletic and functional movements, namely flexion, adduction and internal rotation (commonly called FADIR). Impingement can be defined as an abutment of the femoral head against the acetabulum or decreased joint clearance between the femoral head and the acetabulum. Unlike the concept of impingement, FAI is a motion-related clinical disorder and diagnosis is made based on a triad of symptoms, clinical signs and imaging findings.

Definitions: Cam: bony morphology of anterior/superior femoral neck (head-neck junction) Pincer: deep acetabulum or over coverage of the acetabulum over the femoral head Mixed: a combination of both It is important to note that not all individuals who present with Cam/Pincer/Mixed morphologies have FAI. There is a movement-related contribution, so the goal of rehab is to optimize movement to improve the distribution of joint loads and reduce excessive impingement.

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9.2 ANATOMY AND FUNCTION OF THE HIP MUSCULATURE

The deep rotators of the hip, similarly to the rotator cuff of the shoulder, act to stabilize the hip to prevent excessive anterior glide of the femoral head. As a matter of fact, they are sometimes referred to as the hip rotator cuff. These short external rotators are the piriformis, superior gemellus, inferior gemellus, obturator externus, obturator internus. The glute max and posterior fibers of the glute med also contribute a posterior pull on the head of the femur, so if they are not functioning well, this can result in excessive anterior glide of the humeral head.

Pelvic tilt is the ultimate consideration of the core. -Shirley A. Sahrmann

As we have seen in Level, 1, there is a complex relationship between the glutes, abdominals, and hip flexors. The psoas is often tagged as the cause, when more often it is the effect of an imbalance in the coordinated action of these muscles.

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SECTION 10 UNDERSTANDING LOW BACK PAIN 10.1 LOW BACK PAIN: RELEVANT CLINICAL INFORMATION Low back pain (LBP) is one of the leading causes of activity limitation and workplace disability. Four out of 5 adults will experience at least one episode of back pain at some time in their lives. Some incidence of LBP can be attributed to an actual diagnosis, most commonly disc bulges and disc herniations, spondylolisthesis, degenerative disc disease and facet joint arthropathy. As much as 85-90% of patients present clinically with non-specific LBP, which means there is no pathoanatomical cause for the pain. Regardless of whether there is a specific diagnosis or not, what is most important to know is that there will be specific loads, postures and positions that are pain-triggering.

“There are many tissue-based differential diagnoses. The pain might be coming from a disc, a sacroiliac joint, a facet. We can get close to the tissues…(…) but you never will, nor will it matter to you

to know what the precise bio anatomical pain trigger is. However, if you can understand which motions, postures and loads make your pain increase and which ones take your pain away, that

would be the most valuable thing you could know.” -Dr. Stu McGill

Degenerative disc disease Degeneration of the discs is considered in many ways a part of the natural aging process. That said, disc degeneration occurs at a faster rate than many other age-related changes, so degeneration can be found in people of working age. Essentially, with increasing age, the water content of the intervertebral disc decreases. While many people may be asymptomatic, the process may cause a cascade of changes such as weakening of the annulus fibrosus and structural changes to the vertebral bodies and endplates. The most important consequence of DDD to consider is that it can generate instability. Disc degeneration results in a loss of disc height which creates laxity between the vertebra as it changes the morphology of the joint. The loss of height also allows results in ligament laxity, which in turn has an implication for the facet joints, which will discuss further below. Presentation:

• may present as pain that worsens with movement • may present with load intolerance to shear and/or compression • commonly presents with extension intolerance due to increased stress on the facet joints

10.2 DISC BULGES AND HERNIATIONS There is sometimes some confusion with the nomenclature of lumbar disc pathology. The term “tear” is used to refer to a localized radial, concentric, or horizontal disruption of the annulus without associated displacement of disc material beyond the limits of the intervertebral disc space. You will find this more commonly referred to as a disc «bulge”. The term disc “herniation” refers to localized displacement of disc material beyond the intervertebral disc space. The most common disc bulges and/or herniations occur at the L5/S1 level (approximately 45%). It is of note that most disc herniations will resorb on their own with proper rehabilitation.

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Presentation:

• typically presents with flexion intolerance • typically presents with load intolerance to compression

*From: Fardon, D. (2001). Nomenclature and Classification of Lumbar Disc Pathology. Spine, 26(5), 461-462.

*With permission from patient file

10.3 SPONDYLOLISTHESIS Spondylolisthesis is the displacement of one vertebra over another secondary to a pars interarticularis fracture (spondylolysis). This occurs most commonly from repetitive stress, particularly in athletes who participate in sports in which the spine is repeatedly bent backwards, such as dance and gymnastics, for example. Presentation:

• typically presents with extension intolerance • typically presents with load intolerance to shear

*From: https://www.pauljeffordsmd.com/spondylolysis-pars-fractures-and-lytic

*From: https://mycentralfitness.com.au/health- nutrition/preparation-recovery/stress-fractures/stress-fracture- of-the-pars-interarticularis-lumbar-spondylolysis/

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10.4 FACET JOINT ARTHROPATHY Facet joint arthropathy is intimately tied to degeneration of the intervertebral discs. Facet joint syndrome is the term often used to differentiate it from disc-related low back pain. Any of the previous conditions of the lumbar spine that we have seen can increase stress on the facet joints because there will be increase movement and/or a resultant change in alignment of the facet joint surfaces. Like the intervertebral discs, the facet joints are also subject to age-related degeneration. Presentation:

• typically presents with extension intolerance • typically present with rotation intolerance • extension + rotation may increase pain

*From: Shi, Jian-gang & Xu, Xi-ming & Sun, Jing-chuan & Wang, Yuan & Kong, Qing-jie & Shi, Guo-dong. (2019). Theory of Bowstring Disease: Diagnosis and Treatment Bowstring Disease. Orthopaedic Surgery. 11. 3-9. 10.1111/os.12417.

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CONGRATULATIONS! You have successfully completed the Movement Optimization for Prehab

and Performance Level 2 Course. We hope that you have obtained from

this course what you are looking for!

We would love to get your feedback!

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