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Tuesday, June 6, 2023

Introduction to Activation Exercise

Brent Brookbush

Brent Brookbush

DPT, PT, MS, CPT, HMS, IMT

Introduction to Activation Exercise:

By Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, H/FS

Definition:

  • Isolated* Activation Technique/Exercise - A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
    • Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.
    • Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, synergistic dominance and compensation patterns.
  • Reactive Activation Techniques - When possible, these exercises start at the end range (or shortened position) used during isolated activation with special attention given to cues for inhibiting overactive synergists . The under-active muscle is challenged to eccentrically decelerate one's own body-weight or a medicine ball, through a full range of motion at a relatively high velocity, followed by stabilization with optimal posture (a hold of 3 - 5 seconds).

*Isolation is best thought of as a relative term. That is, these techniques "isolate" the target muscles as much as possible considering the involved joint action and surrounding/synergistic muscles.

Serratus Anterior Activation

What muscles should we activate?

Movement assessment should guide exercise and technique selection when building a routine/program designed to enhance the quality of human movement, reduce symptoms of pain/discomfort and/or enhance performance. Any program or routine based on assessment should be followed by reassessment, and subsequent modifications to the routine/program should be based on outcomes.

Although every patient/client may present differently, most of the differences between individuals could be viewed as small variations on common compensatory patterns. These compensatory patterns have also been described as "postural dysfunctions" or "movement impairments" in various texts (1-6). Continued effort to understand those common patterns, using an evidence-based approach (integrating research, clinical experience and outcomes), has lead to the development of predictive models of postural dysfunction described by the Brookbush Institute, building on the work of Janda, Lewit, Kendal et al., Sahrmann, Clark et al. and others (1-5). These predictive models of postural dysfunction aid in inferential reasoning, assessment selection, and the development of a repertoire of interventions. For example, if research can correlate maladaptations of various tissues (muscles, joints, nerves and fascial structures) with common diagnoses/pathologies seen in rehab, fitness and performance setting, this may imply a set of techniques (inhibitory, lengthening, mobilization, activation, stabilization, integration, etc) from which a repertoire can be built. Various techniques can then be compared in practice, and eventually become the subject of 3rd part research, and the cycle of research, clinical experience and outcomes continues… It is also important to note that these predictive models of postural dysfunction have the power to highlight gaps in repertoire that should be the focus of our continued ingenuity.

Some postural dysfunctions are so common that they seem to give inference to "hard-wired" alternatives to optimal movement. Various theories have been proposed; however, it is beyond the scope of this article to discuss each. Of these patterns, Upper-Body Dysfunction (UBD) , Lumbo Pelvic Hip Dysfunction (LPHCD) , and Lower Extremity Dysfunction (LED) are likely the most common and should be studied as the foundation for understanding postural dysfunction. Less common are postural dysfunctions of the periphery (Foot/Ankle Dysfunction, Forearm/Wrist Dysfunction, and Cervical/Upper Thoracic Spine Dysfunction), last, we could add the more uncommon variations on each of these patterns, for example Lumbosacral Dysfunction , Functional Varus, Anterior Shoulder Laxity, Inadequate Forward Lean/Posterior Pelvic tilt, etc..

If we compare common predictive models of postural dysfunction we start to notice that each muscle has a propensity toward a common maladaptive change in activity (over-active/under-active) and length (short/long). For example, regardless of the dysfunction, the gluteus maximus has a propensity to become under-active and long. Various texts have discussed these tendencies, most often splitting muscles into two groups - “tonic”(short/overactive) and “phasic” (long/underactive) (1-3). The Brookbush Institute divides maladaptive changes in muscle length and activity a bit further:

Human Movement Science Rule #6:

  • A muscle cannot possess two opposing qualities - A muscle can be either short or long, and may additionally be either over-active or under-active.
    • Most Common
      • Short/Over-Active
      • Long/Under-active
    • Less Common
      • Long/Over-active
    • Relatively rare
      • Short/Under-active

An "activation technique/exercise" is an intervention developed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction. The repertoire of activation exercises discussed in this series of articles has been developed based on a list compiled from the under-active muscles noted in the predictive models of postural dysfunction described by the Brookbush Institute.

Serratus Anterior Manual Muscle Test

Assessment:

Although the predictive models of postural dysfunction are an integral step in the development of a systematic approach to optimal practice, they can only infer the maladaptation of all the structures involved in a postural dysfunction for a given segment (lower extremity, LPHC, upper body). They cannot differentiate or isolate which muscles are actually exhibiting under-activity for an individual patient/client. For this reason, assessment is imperative. Relative to the selection of activation techniques, any assessment that infers under-activity/weakness of muscles may be used to refine exercise selection. This may include (but is not limited to):

Although it is a fairly indirect approach based on concepts of altered reciprocal inhibition, length/tension relationships and arthorkinematic dyskinesis; some mobility assessments may be used to refine the selection of activation techniques. For example, goniometry may highlight a lack of dorsiflexion which may imply gastrocnemius and soleus over-activity and altered reciprocal inhibition resulting in tibialis anterior under-activity.

It is the recommendation of the Brookbush Institute that movement assessment starts with a Overhead Squat Assessment to infer dysfunctional segments and compensation patterns, followed by mobility assessments including Goniometry to refine mobility technique selection and add objective measurements, and continue with Manual Muscle Tests (MMT's) to refine the selection of activation techniques. Although the reliability and objectivity of MMTs have been the target of scrutiny and criticism, they are still the most direct assessment of muscle under-activity and weakness.

What is the goal of Activation Techniques?

The goal of activation techniques is to enhance neural drive, motor unit recruitment, intra- and inter-muscular coordination, synchronization and firing rate of muscles presumed to be under-active. Research has demonstrated an increase in neural drive post isolated resistance training (2), alterations in synchronization post neuromuscular re-education (1, 9, 10), and alterations in the rate of motor unit recruitment post reactive training (9). Several studies have shown positive changes in movement patterns post targeted resistance training, and the exercises used in these studies are often similar to the activation techniques described in this series of articles (8-43). Although there is still much research to be done, the use of these techniques in rehab, fitness and performance settings has proven overwhelmingly positive. In practice, the use of these techniques should follow release, mobilization and lengthening techniques to ensure that activation can be achieved through a full ROM (with less contribution from over-active synergists). Successful implementation of the techniques should result in immediate, measurable change in the quality of movement. Presumably, these changes result from an increase in muscle activity and less reliance on compensatory movement patterns.

Hop Down to Single Leg Touchdown (Progression for Tibialis Posterior and Glute Complex Reactive Activation)

Reactive Activation: A New Addition to Activation Techniques -

  • Reactive Activation Techniques - When possible, these exercises start at the end range (or shortened position) used during isolated activation with special attention given to cues for inhibiting overactive synergists . The under-active muscle is challenged to eccentrically decelerate one's own body-weight or a medicine ball, through a full range of motion at a relatively high velocity, followed by stabilization with optimal posture (a hold of 3 - 5 seconds).

Reactive activation exercises are my attempt to refine techniques designed with the intent of enhancing the firing rate and synchronization of under-active muscles (achieve faster recruitment). These techniques are done post "isolated activation" with the same intent "post-activation potentiation (PAP)/complex training" is used to maximize power/force output in performance training. That is, a power exercise immediately follows a maximum strength exercise with a similar set of joint actions to optimize motor unit recruitment before challenging firing rate (8). Once motor unit recruitment has been enhanced and synergistic dominance reduced using isolated activation, firing rate is challenged using "reactive activation exercises" by creating a stimulus to eccentrically decelerate "higher" velocity loads from a position of "optimal activation." Progressing reactive activation exercise is likely best thought of as being similar to how exercise is progressed to challenge stability rather than how a traditional power exercise is progressed. That is, progression should include changing planes, adding less stable environments, increasing complexity, or increasing distance. (Practically speaking, reactive activation for upper body dysfunction increases in complexity from external rotator activation to serratus anterior activation to trapezius activation ). Increasing the load and velocity of reactive activation exercise may be appropriate as a bridge between "corrective/therapeutic exercise" to traditional power training, but this likely most appropriate for an athletic population.

Integration Techniques:

Post mobility and activation techniques it is important to "integrate" the new motor program into larger multi-segmental movement patterns. Licensed professionals now this practice as neuromuscular re-education. The Brookbush Institute  simply adds another layer of thought to this practice in an attempt to further refine exercise selection with consideration to inter-muscular coordination and subsystem recruitment.

Inter-muscular coordination or "stability integration" is an exercise that is selected to challenges the under-active muscles in a movement impairment to maintain equilibrium under relatively unstable conditions. The exercises I most commonly use for this goal are:

Subsystem integration is a way of refining our selection of a total body movement pattern to end our rehabilitation and integrated warm-up interventions. This includes legs with pull, legs with push, and legs with press. Although the practical application of subsystem integration is actually quite simple, the theory behind it is a bit complex. For more on subsystem integration, please see Core Subsystems .

Deep Cervical Flexor Activation - http://youtu.be/SLfXiM5ENzU

Activation in Practice:

Not all muscles are easily activated, and some under-active muscles are grouped together during a single activation technique. The following is a list of articles covering the exercise progressions most commonly used by the Brookbush Institute. The implementation of these techniques is done in conjunction with an integrated approach to optimizing motion. Generally as part of the Rehabilitation Template and/or Integrated Warm-Up templates described below under "Order of Treatment" (printable PDF of the Integrated Warm-up Template below)

Acute Variables (1-9):

Isolated Activation

  • Resistance Progression: Manually assisted with tactile cuing --> manually resisted with tactile cuing --> self-administered.
    • Manual Resistance: Verbally cue patient effort and apply appropriate manual resistance. As ideal form and range of motion is achieved at a given level of intensity, ask the patient to apply more force in graded fashion.
      • One set may include 5 - 15 reps in the following sequence:
        • Without significant effort for 1-5 reps ("just attempt the motion")
        • 25% effort for 1-2 reps ("some or minimal effort")
        • 50% effort 1-2 reps ("half your max or moderate effort")
        • 75% effort 1-2 reps ("strong effort")
        • 100% effort 1-3 reps ("everything you got")
    • Self-Administered:
      • Loads are generally low (when compared to resistance training exercise) to ensure ideal form without compensation and the fullest range of motion the client can attain. Allow form and rep range to dictate load.
  • Reps:
    • 5-15 for manual resistance
    • 12 - 20 for self-administered
  • Sets: 1-2 sets
  • Tempo (Eccentric: Isometric: Concentric)
    • 4:2:2 to promote eccentric control
    • 2:4:2 to promote strength at end range

Reactive Activation:

  • Load: Light - only as much load/velocity as can be controlled with optimal form
  • Reps: 12 - 20
  • Sets: 1-2
  • Tempo: Quick but controlled tempo (optimal eccentric deceleration) to 3-4 second stabilization (isometric contraction). Stability Integration and Subsystem Integration:
  • Load: Moderate - only as much load as can be controlled with optimal form
  • Reps: 12 - 20 reps (or 30 seconds to 2:00 minutes)
  • Sets: 1-2 sets
  • Tempo (Eccentric: Isometric: Concentric)
    • 4:2:2

Order of Exercise and Activation Circuits:

  • First Mobility:
    • Release, lengthening and mobilization techniques should precede activation techniques. This premise is based on altering length/tension relationships, decreasing muscle activity of functional antagonists, reducing altered reciprocal inhibition, decreasing the activity of over-active synergists, improving arthrokinematics, and increasing the available range of motion for activation techniques. That is, if mobility techniques do not precede activation techniques it is challenging to recruit the target muscle without also recruiting over-active synergists, and activation techniques cannot be performed through a ROM that is not currently available. The techniques considered under mobility include trigger point (static) release, active release, positional release, instrument assisted soft-tissue techniques, static stretching, active stretching, and joint mobilization/manipulation.
  • Second Activity and Integration (1):
    • Activation and integration techniques are placed in order of relative isolation, relative intensity and relative complexity (number of moving joints). Initially specific structures are targeted (1), followed by integrating under-active muscle synergies (this could be viewed from the perspective of motor control, i.e. Richardson et. al (4)), then more intense exercise with the goal of improving firing rate (2), and finally cued practice and facilitation of integrated functional tasks. The modalities of exercise in this category would include activation, reactive activation, rhythmic perturbation, core activation, PNF, RNT, stability integration, subsystem integration , functional training for optimal performance of ADL’s, and potentially taping techniques.
    • The Feel of It - It is the intent of Brookbush Institute that human movement professionals will artfully select exercises for the "Activity" portion of the template that can be done sequentially in "circuit" (one set per exercise with no rest between exercises) - creating an "Activity Circuit". For fitness and performance enhancement professionals, this portion of the template is meant to replace the "warm-up" (as well as core and flexibility training) before resistance training, cardiovascular training and practice. For the rehabilitation professional, gradually adding each exercise type to the template (starting with isolated activation, then core integration, then reactive activation, etc) starts to build a program that transitions from "rehab" to "strength and conditioning". This transition is a gap in the current rehabilitation model, and the Brookbush Institute believes this gap can be seen in recidivism rates. Two or three times through the "Activity" portion of the template below, in circuit, can be quite challenging. Some helpful tips below:
      • Build the program over several session to include at least one exercise per category
      • "Isolated Activation" to "Subsystem Integration" is done in circuit (gather equipment into a small area in advance)
      • Exercises should increase in intensity from "Isolated Activation" to "Subsystem Integration"
      • Be careful not to rely too heavily on unilateral exercises as this will increase the time to completion and significantly decrease intensity.

Brookbush Institute - Corrective Exercise/Movement Preparation Template (For use by all professionals):

Mobility:

  • Release
  • Mobilize (When Appropriate)
  • Stretch

Activity: (Perform each exercise for 12-20 reps, in circuit, for 1-3 sets):

  • Isolated Activation
  • Core Integration (Optional)
  • Stability Integration (Optional)
  • Reactive Activation (Optional)
  • Subsystem Integration

Reinforce:

  • Kinesiology Taping
  • Home Exercise Program
  • Education Materials
  • Follow-up

Download a printable PDF version: Corrective-Exercise-Template

Tibialis Posterior Activation Progression 4

Practice makes perfect:

I know this appears to be more techniques than are possible in the time allotted for a single appointment, but I assure you that practice will lead to proficiency, efficiency, and allow you to flow through the template with ease. I would expect to finish the Integrated Warm-Up Template in 20-30 minutes of an hour session, with activation portion taking 8 - 10 minutes per circuit. Note, it may take several sessions to build an "Activity Circuit". Allow yourself and your patient/client time to get accustomed to each individual exercise, and be willing to postpone the addition of new technique for mastery of the techniques already in the program.

Some Helpful Tips:

  • Practice the programs yourself
  • Practice on co-workers
  • Have sample programs (protocols) for each dysfunction/joint to fall back on
  • Move the equipment used for a particular set of techniques to one small area
  • Initially, write your routine before the session begins (make corrective exercise as simple as following a list of exercises)
  • Instruct an individual about the next exercise while waiting for a release, or for a client to finish a set.
  • Be setting-up exercises and grabbing equipment as it is safe to leave your client to do so.

Giving Credit Where it is Due:

When I was faculty for Town Sports International (TSI, NYSC), Dr. Mike Clark (former creator of the OPT Model, former CEO of the National Academy of Sports Medicine (NASM), current CEO of Fusionetics) gave a private lecture for the fitness education department. I had the privileged opportunity to be one of a dozen people at that lecture. During that lecture Dr. Clark introduced the concept of circuits for commonly weak/under-active musculature. These circuits were already being successfully piloted with professional sports teams using various orders of exercise based on the NASM CES model. It has been the refinement of this idea that has lead me to the development of “activation circuits” and a large portion of the “Integrated Warm-up Template.” Many thanks to an inspiring figure in our industry who seems to be an unlimited source of ideas and innovation.

Bibliography

  1. Dr. Mike Clark & Scott Lucette, “NASM Essentials of Corrective Exercise Training” © 2011 Lippincott Williams & Wilkins
  2. Shirley A Sahrmann, Diagnoses and Treatment of Movement Impairment Syndromes, © 2002 Mosby Inc.
  3. Phillip Page, Clare Frank, Robert Lardner, Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
  4. Karel Lewit. Manipulative Therapy: Musuloskeletal Medicine © 2007 Elsevier
  5. Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance, Mary McIntyre Rodgers, William Anthony Romani, Muscles: Testing and Function with Posture and Pain: Fifth Edition © 2005 Lippincott Williams & Wilkins
  6. Leon Chaitow, Muscle Energy Techniques: Third Edition, © Pearson Professional Limited 2007
  7. Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004
  8. Clark, M., Lucett, S., & Kirkendall, D. T. (2010). NASM's essentials of sports performance training. Lippincott Williams & Wilkins
  9. Bruhn, S., Kullmann, N., & Gollhofer, A. (2004). The effects of a sensorimotor training and a strength training on postural stabilisation, maximum isometric contraction and jump performance. International journal of sports medicine, 25(01), 56-60
    • Multiple Muscles:
  10. Padua, D. A., Bell, D. R., & Clark, M. A. (2012). Neuromuscular characteristics of individuals displaying excessive medial knee displacement. Journal of athletic training, 47(5), 525
    • Tibialis Posterior
  11. Kulig, K., J. M. Burnfield, S. M. Requelo, M. Sperry, and M. Terk. Selective Activation of Tibialis Posterior: Evaluation by Magnetic Resonance Imaging. Med. Sci. Sports Exerc., Vol. 36, No. 5, pp. 862–867, 2004.
  12. Alvarez R., Marini A, Schmitt C, Saltsman C. Stage I and II Posterior Tibial Tendon Dysfunction Treated by a Structured Nonoperative Management Protocol: An Orthosis and Exercise Program Foot Ankle Int January 2006 27: 2–8
  13. Kulig K, Lederhaus E, Reischl S, Arya S, Bashfor G. Effect of Eccentric Exercise Program for Early Tibialis Posterior Tendinopathy Foot & Ankle International September 2009 vol. 30 no. 9 877-885
  14. Kulig K, Burnfeld JM, Reischl S, Requejo SM, Blanoc CE, Thordarson DB. Effect of foot orthoses on tibialis posterior activation in persons with pes planus. Medicine and Science in Sports and Exercise 2005, 37(1):24-29
    • Tibialis Anterior
  15. Lemos T, Imbiriba LA, Vargas C, et al. (2015). Modulation of tibialis anterior muscle activity changes with upright stance width. Journal of Electromyography and Kinesiology. 168-174.
  16. Chon S, You JH, Saliba SA. (2012). Cocontraction of ankle dorsiflexors and transversus abdominis function in patients with low back pain. Journal of Athletic Training. 47(4): 379-389
    • Gluteus Medius
  17. Bell, D. R., Oates, D. C., Clark, M. A., & Padua, D. A. (2013). Two-and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. Journal of athletic training,48(4), 442-449.
  18. Ramskov, D., Barton, C., Nielsen, R. O., & Rasmussen, S. (2015). High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year Observational Study. journal of orthopaedic & sports physical therapy, 45(3), 153-161
  19. Snyder, K. R., Earl, J. E., O’Connor, K. M., & Ebersole, K. T. (2009). Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clinical Biomechanics, 24(1), 26-34
  20. Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501.
    • Gluteus Maximus
  21. Kan, S., Jeon, H., Kwon, O., Cynn, H., Choi, B. (2013). Activation of the gluteus maximus and hamstring muscles during prone hip extension with knee flexion in three hip abduction positions. Manual Therapy 18, 303-307
  22. Boren K, Conrey C, Le Coguic J, Paprocki, L,Voight M, Robinson. Electromygraphic Analysis of the Gluteus Medius and Gluteus Maximus during Rehabilitation Exercises. Int J Sports Phys Ther. 2011 Sep; 6(3): 206–223
  23. Berry, J. W., Lee, T. S., Foley, H. D., & Lewis, C. L. (2015). Resisted Side Stepping: The Effect of Posture on Hip Abductor Muscle Activation. Journal of Orthopaedic & Sports Physical Therapy, 45(9), 675-682.
  24. Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? electromyographic assessment using fine-wire electrodes. journal of orthopaedic & sports physical therapy, 43(2), 54-64
  25. Queiroz, BC., Cagliari, MF., Amorim, CF., Sacco, IC. Muscle Activation During Four Pilates Core Stability Exercises in Quadruped Position. Arch Phys Med Rehabil 2010;91:86-92.
    • Transverse Abdominis
  26. Hides, J. A., Richardson, C. A., & Jull, G. A. (1996). Multifidus Muscle Recovery Is Not Automatic After Resolution of Acute, First‐Episode Low Back Pain.Spine, 21(23), 2763-2769.
  27. Hides, J. A., Jull, G. A., & Richardson, C. A. (2001). Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine, 26(11), e243-e248.
  28. Sihawong, R., Janwantanakul, P., Jiamjarasrasi, W. (2014) A prospective, cluster-randomized controlled trial of exercise program to prevent low back pain in office workers. European Spine Journal 23:786-793
  29. O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. (1997). Evaluation of specific stabilizing exercise in treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 22(24): 2959-2967.
    • Serratus Anterior
  30. Park, Se-yeon, and Won-gyu Yoo. “Differential activation of parts of the serratus anterior muscle during push-up variations on stable and unstable bases of support.” Journal of Electromyography and Kinesiology 21.5 (2011): 861-867.
  31. Decker, M. J., Hintermeister, R. A., Faber, K. J., & Hawkins, R. J. (1999). Serratus anterior muscle activity during selected rehabilitation exercises. The American journal of sports medicine, 27(6), 784-791. (none of the exercises selected in this study used upward rotation to target the serratus anterior)
  32. Ludewig, P. M., Hoff, M. S., Osowski, E. E., Meschke, S. A., & Rundquist, P. J. (2004). Relative balance of serratus anterior and upper trapezius muscle activity during push-up exercises. The American journal of sports medicine, 32(2), 484-493.
  33. Hardwick DH, Beebe JA, McDonnell MK, Lang CE. (2006). A comparison of serratus anterior muscle activation during a wall slide exercise and other traditional exercises. Journal of Orthopaedic & Sports Physical Therapy. 36(12) 903-910
    • Trapezius
  34. Cools, A.M., Dewitte, V., Lanszweert, F., Notebaert, D., Roets, A., Soetens, B., Cagnie, B., Witvrouw, E.E. (2007) Rehabilitation of Scapular Muscle Balance. Which Exercises to Prescribe? Am J Sports Med, 35(10), 1744-1751.
  35. Ha, Sung-min., Kown, Oh-yum., Cynn, Heon-seock., Lee, Won-hwee., Park, Kyue-nam., Kim, Si-hyun., & Jun, Do-young. (2012) Comparison of electromyographic activity of the lower trapezius and serratus anterior muscle in different arm-lifting scapular posterior tilt exercises. Physical Therapy in Sport, 13, 227-232.
    • External Rotators
  36. Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, Cody RC, Jameson GG, Andrews JR. Electromyographic Analysis of the Rotator Cuff and Deltoid Musculature During Common Shoulder External Rotation Exercises. J Orthop Sports Phys Ther. 2004 Jul;34(7):385-94
  37. Ha, S., Kwon, O., Cynn, H., Lee, W., Kim, S., Park, K. (2013). Selective activation of the infraspinatus muscle. Journal of Athletic Training. 48(3). 346-352
  38. Daisuke Uga, Yasuhiro Endo, Rie Nakazawa, Masaaki Sakamoto. Electromyographic analysis of the infraspinatus and scapular stabilizing muscles during isometric shoulder external rotation at various shoulder elevation angles. J Phys Ther Sci. 2016 Jan; 28(1): 154–158
    • Deep Cervical Flexors
  39. Falla, D., O’Leary, S., Fagan, A., & Jull, G. (2007). Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual therapy, 12(2), 139-143
  40. Jull, G.A., Falla, D., Vicenzino, B., Hodges, P.W. (2009). The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Therapy. 14: 696-701.
  41. Falla, D., O’Leary, S., Fagan, A., & Jull, G. (2007). Recruitment of the deep cervical flexor muscles during a postural-correction exercise performed in sitting. Manual therapy, 12(2), 139-143
  42. Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., … & Richardson, C. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 27(17), 1835-1843
  43. Van Ettekoven, H., & Lucas, C. (2006). Efficacy of physiotherapy including a craniocervical training programme for tension‐type headache; a randomized clinical trial. Cephalalgia, 26(8), 983-991.

© 2017 Brent Brookbush

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